Air Force Waiver Guide


Bicuspid Aortic Valve (Oct 10)



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Bicuspid Aortic Valve (Oct 10)



I. Overview.
Bicuspid aortic valve (BAV) occurs in 1-2% of the general U.S. population and is the most common congenital cardiac malformation, excluding mitral valve prolapse.1, 2 The prevalence of BAV has been about 0.6% in the United States Air Force (USAF) database of Medical Flight Screening echocardiograms (echo) performed on pilot training candidates.3, 4 Over 70% of BAV subjects will develop some degree of aortic stenosis (AS) and/or aortic insufficiency (AI) during their lifetime. Additionally, 30-40% will require surgical placement of a prosthetic aortic valve during their lifetime, predominantly after the age of 45 years.3, 4
In early 2007, the American Heart Association published new infective endocarditis guidelines that are dramatically different from past recommendations.5 Endocarditis prophylaxis was recommended only for specified high risk groups, and only for dental procedures, respiratory tract procedures, and procedures on infected skin, skin structures or musculoskeletal tissue. The high risk group was limited to prosthetic cardiac valves, previous endocarditis, select congenital heart conditions and cardiac transplant patients with valvulopathy. Prophylaxis was no longer recommended for gastrointestinal or genitourinary procedures. Conditions commonly seen by most aerospace medicine practitioners were not included in the list of high risk conditions. Such common conditions no longer recommended for endocarditis prophylaxis include, but are not limited to, mitral valve prolapse, bicuspid aortic valve, mitral or aortic regurgitation with normal valve (e.g. primary MR) and uncorrected small defects of the atrial and ventricular septum.
II. Aeromedical Concerns.
Aeromedical concerns include the development and progression of AS and/or AI. Risk of a sudden incapacitating event is very low and aeromedically acceptable in the absence of significant AS or severe AI.1, 2, 3, 4 Waiver policies are thus primarily dependent on the presence and severity of associated AS and AI. AI severity is graded by echo as: trace, mild, moderate and severe. AS is graded by echo as: mild, mild-to-moderate, moderate and severe.3 Please refer to the AS and AI waiver guides for further details.
Medications to reduce afterload, such as ACE inhibitors and nifedipine, have documented clinical benefit in chronic significant AI, including delaying the need for surgery and improvement of surgical outcome. The use of approved ACE inhibitors and nifedipine is therefore acceptable in aviators with asymptomatic moderate and severe AI.3

III. Waiver Consideration.
Per AFI 48-123, BAV is disqualifying for all classes of flying duties, however it is not listed as disqualifying for FC IIU, ATC/GBC, or SMOD duties. If BAV is associated with symptomatic aortic stenosis, it is disqualifying for FC IIU and ATC/GBC duties. Aortic disease (or any valvular disease) is disqualifying for all flying classes (including SMOD, ATC/GBC, and FC IIU) per retention standards.
ACS review is required for waiver consideration. ACS evaluation may be required, depending on the flying class or for specific concerns in an individual case. As stated above, waiver recommendations are primarily dependent on the presence and severity of associated AS and AI. FC I and IA will only be waiver eligible for BAV with ≤ mild AI and no AS; any greater AI or any AS is not waiver eligible. FC II/III requires ACS evaluation for waiver consideration. ACS re-evaluations will be performed at 1-3 year intervals, depending on the degree of AI and/or AS and other related conditions such as chamber dilation, left ventricular function and left ventricular hypertrophy. As discussed above, the use of approved ACE inhibitors and nifedipine for afterload reduction is acceptable in aviators with BAV and asymptomatic moderate or severe AI.3 Waiver may be considered after surgery; please refer to the “Valve Surgery – Replacement or Repair” waiver guide. Table 1 is a summary of the clinical manifestations and most common requirements for the separate flying class (FC) duties.
If the disease process appears mild and stable, waiver for all classes of flying duties will generally be valid for three years with ACS reevaluation/review at the time of waiver renewal. Each waiver recommendation will specify requirements and timing for waiver renewal.

Table 1. Summary of BAV and Associated Clinical Conditions and ACS Requirements.

BAV and Associated Levels of Aortic Stenosis (AS) and/or Aortic Insufficiency (AI)

Flying Class

Waiver Potential
Waiver Authority

Required ACS Review and/or ACS Evaluation

BAV with no, trace or mild AI (≤mild) and no AS
BAV with >mild AI or any AS

FC I/IA

FC I/IA


FC IIU

ATC/GBC


Yes

AETC
No

AETC
Yes

AFMSA**
Yes

MAJCOM


ACS review

ACS review

ACS review

ACS review




BAV with < mild AI and/or < mild AS

FC II/III

FC IIU


ATC/GBC

Yes

MAJCOM
Yes

AFMSA**
Yes

MAJCOM


ACS evaluation

ACS review

ACS review


BAV with moderate AI and/or mild-to-moderate AS


FC IIA

FC III


(low performance only)

Yes

AFMSA


Yes

MAJCOM


ACS evaluation

ACS evaluation




BAV with severe AI only – asymptomatic and nonsurgical AI per guidelines

FC IIA only

FC III (low performance only)


FC IIU

ATC/GBC


Maybe*

MAJCOM
Maybe*

MAJCOM
Maybe

AFMSA**
Maybe

MAJCOM


ACS evaluation

ACS evaluation

ACS Review

ACS Review



BAV with > moderate AS† or with severe AI‡ surgical by guidelines

FC II/III

FC IIU


ATC/GBC

No

MAJCOM
Maybe

AFMSA**
Maybe

MAJCOM


ACS review

ACS review to confirm


ACS review to confirm

* Waiver in untrained FC II and III individuals unlikely.

** Certification authority for FC IIU (untrained) is AETC

† Moderate to severe AS requires medical evaluation board (MEB).

‡ Severe AI if symptomatic and associated with left ventricular dilation or dysfunction requires MEB.


AIMWITS search in late August 2010 revealed a total of 199 individuals with an aeromedical summary that included a diagnosis of BAV. Included in this total were 32 FC I/IA cases (6 disqualifications), 120 FC II cases (12 disqualifications), 39 FC III cases (6 disqualifications), 1 FC IIU cases (1 disqualification), 2 ATC/GBC cases (1 disqualification), and 3 SMOD cases (0 disqualifications). Out of the 199 total cases, 29 had no gradable AI (1 disqualification due to exercise-induced syncope).
IV. Information Required for Waiver Submission.
Aeromedical Consultation Service (ACS) review/evaluation is required for all classes of flying duties for BAV with or without AI/AS. No additional studies are routinely required prior to ACS evaluation. If however, the treating physician deems it clinically necessary to perform additional studies, it is required that all studies be forwarded to the ACS for review. There is no minimum required non-flying observation period for waiver consideration for BAV, regardless of the presence or severity of AI or AS.
The aeromedical summary for initial waiver for BAV (initial ACS evaluation) should include the following:

A. List and fully discuss all clinical diagnoses requiring a waiver.

B. Complete history and physical examination – to include detailed description of symptoms, medications, activity level and CAD risk factors (positive and negative).

C. Copy of the local echo report and videotape or CD copy of the echo documenting BAV. (Notes 1 and 2)

D. Copies of reports and tracings of any other cardiac tests performed locally for clinical assessment (e.g. Holter, treadmill, stress echocardiogram). (Notes 1 and 2)

D. Additional local cardiac testing is not routinely required but may be requested in individual cases.


The aeromedical summary of waiver renewal for BAV [ACS follow-up evaluations] should include the following:

A. Complete history and physical examination – to include detailed description of symptoms, medications and activity level.

B. Local follow-up cardiac testing is not routinely required prior to ACS re-evaluation. If requested for individual cases, it will have been specified in the report of the previous ACS evaluation.

C. Copies of reports and tracings of any other cardiac tests performed locally for clinical assessment (e.g. Holter, treadmill, stress echocardiogram). (Notes 1 and 2)


Note 1: The address to send videotape/CD and reports not attached in AIMWTS is:

Attn: Case Manger for (patient’s MAJCOM)

USAFSAM/FECI

Facility 20840

2510 Fifth Street

WPAFB, OH 45433-7913

For expediting the case, recommend sending via FedEx. Include patient’s name, SSN and POC at base.

Note 2: State in AMS when studies were sent to ACS.


ICD 9 code(s) for Bicuspid Aortic Valve

746.4

Congenital insufficiency of aortic valve


V. References.
1. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. 36th Bethesda conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities. Task force 3: Valvular heart disease. J Am Coll Cardiol. 2005; 45(8): 1334-40.
2. Bonow RO, chair. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2006; 48(3): e1-e148.
3. Kruyer WB. Cardiology. In: Rayman RB, ed. Clinical Aviation Medicine, 4th ed. New York: Graduate Medical Publishing, LLC, 2006; 187-96.
4. Kruyer WB, Gray GW, Leding CJ. Clinical aerospace cardiovascular medicine. In: DeHart RL, Davis JR eds. Fundamentals of Aerospace Medicine, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002; 348-49 and 352.
5. Wilson W, chair. Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation. 2007; 115: 1-19.

WAIVER GUIDE



Initial Version: Nov 2010

By: Dr Dan Van Syoc
CONDITION:

Birth Control (Nov 10)



I. Overview.
Air Force aviators lead busy lives and those desiring children generally wish to plan for this event. Current estimates are that half of all pregnancies are unplanned and in approximately half of these unintended pregnancies, contraception of some type was being used.1, 2 The options available to men and women are much greater than in previous generations and the flight surgeon can play a pivotal role in aiding in the best choice for the couple involved. Factors to consider in the choice of a contraceptive method include efficacy, convenience, duration of action, reversibility once the decision to conceive has been made, effect on uterine bleeding, frequency of side effects and adverse events, affordability, protection against sexually transmitted diseases, and a wish for a more permanent solution.1
Options for women include natural methods, barrier methods, oral contraceptives (hormonal agents), transdermal patches, vaginal rings, intrauterine devices, and sterilization. Natural methods refer to the timing of intercourse that does not involve the days surrounding an expected ovulation. This method, to be successful, requires predictable cycles, assessment of basal body temperature and cervical mucus, and a highly motivated and disciplined couple. Barrier methods for women include the diaphragm and female condom. Each of these methods must be done in conjunction with a spermicidal lubricant and also requires diligence on the part of the couple. If used properly, the failure rate can be as low as 2.4 per 100 woman-years.3
In the US, the combined estrogen-progestin oral contraceptive (OC) preparations have proved to be the most effective method of contraception, with pregnancy rates reported as less than 0.5 per 100 woman-years. Most compounds include 35 μg or less of estrogen and varying amounts of progestins. OCs can be started anytime during the female’s cycle. Traditionally, OC usage has begun on the first Sunday after the woman’s period begins, but recently most providers are switching to the Quick Start method in which the woman begins her pill on the day the prescription is given as long as pregnancy has been excluded. It is important that the woman take the pill each day as missed pills are the most common cause of contraceptive failure.1, 3 Two related methods of contraception are the progestin only pills and depot medroxyprogesterone acetate (DMPA). Progestin only pills are an option for women who desire an OC, but need to avoid estrogen. This method is associated with more unscheduled (breakthrough) bleeding and slightly higher failure rates than traditional OCs. DMPA is the only injectable contraceptive option in the US. In most cases, it is given by deep intramuscular injection (150 mg) and is effective for three months. A new lower-dose DPMA formulation is administered subcutaneously every three months. In addition, there are a few contraceptive implants available that provide a constant slow release of a progestin. These implants can be left in place for up to five years and the primary complaint in women is irregular bleeding.3
A new option available to women is the transdermal patch which was approved for use in the US in 2002. It is similar to the OCs but is applied topically and only requires three weekly applications per month. A recent review has found that the efficacy of the patch was similar to the OC and user satisfaction has been high. A similar new product is NuvaRing® which is a flexible, single-size contraceptive vaginal ring that was introduced to the US market in 2001. The ring releases an estrogen and progestin combination at a constant rate for the three-week period of use. Review of recent usage data reveals that the ring has an effectiveness rate similar to OCs, a low incidence of adverse events and a high satisfaction rate among users. Both of these newer methods have the additional benefit of easy reversibility after cessation of use.2
Worldwide the intrauterine device (IUD) is the most widely used form of reversible birth control. In the US only 2% of women using contraception utilize this method. The two FDA-approved devices are the copper T380A® and the LNG IUS® (Mirena). The copper T380A® consists of a T-shaped frame made of a polyethylene blend. The active component is 380 mm2 of exposed copper surface area in the form of copper wire wound on the stem and copper collars on the horizontal arms. The copper ions released into the endometrium are toxic to sperm and provide the prefertilization contraceptive effect. The LNG IUS® is also a T-shaped device, but the active ingredient, LNG, is contained in a steroid reservoir around the stem. The reservoir releases 20 mg per day of LNG directly into the uterine cavity. Contrary to widely-held misconceptions, the IUD is one of the most effective and safe methods of contraception. There is also very little risk of post-use infertility as there was with some of the earlier used IUDs.4
The last method to discuss for women is that of sterilization. For women, this is the tubal ligation or tubal obstruction. Both are potentially reversible, but the patient needs to be counseled that it is a permanent procedure. The most convenient time to perform at tubal ligation/obstruction procedure is in the postpartum period. Unfortunately, these are the women most likely to regret sterilization. Pregnancy after tubal sterilization is uncommon, and the risk with such a pregnancy is an ectopic pregnancy.1
For men, the only two methods used effectively are the use of condoms and vasectomy. Condoms are convenient in that they do not require a prescription. If used correctly (not removed until after intercourse completed and used each time) and with a spermicidal agent, the effectiveness can approach that of hormonal contraceptives. They have the added benefit of protection against most sexually transmitted diseases.1 The last method for men is vasectomy which is a sterilization technique. Vasectomy is the most commonly performed urologic surgical procedure performed in the US, with an estimated 500,000 each year. It is employed by nearly 11% of all married couples, but is less prevalent than is tubal procedures in women. The irony of this is that vasectomy is less expensive, and associated with less morbidity and mortality than tubal procedures. As with tubal procedures, adequate counseling is necessary to include discussion that the procedure is not 100% effective. With an experienced surgeon who insists on a postvasectomy semen analysis, it is unusual to have a pregnancy result months to years after the procedure.5, 6

II. Aeromedical Concerns.
Recognized risks with the use of oral contraceptives containing estrogen compounds include nausea, breast tenderness, and breast enlargement. Pills with lower estrogen doses have an increased incidence of monthly breakthrough bleeding. Pills with the newer progesterone compound drospirenone can theoretically lead to hyperkalemia. The more commonly used formulations have a lower dose of estrogen and this can lead to a 3-to-4 fold increase in the risk of thromboembolism. If the woman is a smoker and older than age 35, estrogen-containing pills are not recommended due to the increased risk of thromboembolic disease. The same is true for women with uncontrolled hypertension, diabetes with end-organ damage, or migraine headaches with focal neurological symptoms. If the woman is well screened and has no adverse effects, there is no aeromedical contraindication for the use of oral contraceptives.7 Neither tubal ligation/obstruction procedures or vasectomy have any adverse health consequences once healing has completed, so there are also no contraindications to flying after these procedures.
III. Waiver Consideration.
Waiver is not required for birth control with approved medications or successful sterilization surgery without chronic adverse effects.
IV. Information Required for Waiver Submission.
N/A
V. References.
1. Zieman M. Overview of contraception. UpToDate. Online version 18:2. Jun 2010.
2. Swica Y. The Transdermal Patch and the Vaginal Ring: Two Novel Methods of Combined Hormonal Contraception. Obstet Gynecol Clin N Am, 2007; 34:31-42.
3. Katz VL. Postpartum Care. Ch. 21 in Gabbe: Obstetrics: Normal and Problem Pregnancies, 5td edition, Elsevier, 2007.
4. MacIsaac L and Espey E. Intrauterine Contraception: The Pendulum Swings Back. Obstet Gynecol Clin N Am, 2007; 34:91-111.
5. Sandlow JI, Winfield, HN, and Goldstein M. Surgery of the Scrotum and Seminal Vesicles. Ch. 34 in Campbell-Walsh Urology, 9th edition, Saunders, 2007.
6. Art KS and Nangia AK. Techniques of Vasectomy. Urol Clin N Am, 2009; 36:307-16.
7. Choice of Contraceptives. Treatment Guidelines from the Medical Letter, 2007; Vol 5 (Issue 64).

WAIVER GUIDE



Updated: Jun 09

Supersedes Waiver Guide of Oct 98

By: Maj Ken Egerstrom (RAM 09B) and Dr. Dan Van Syoc
CONDITION:

Bladder Cancer (Jun 09)



I. Overview.
Bladder cancer is the fourth most common cause of cancer in males and affects men three times more frequently than women. Its incidence also increases with age, with 90% of cases occurring in individuals over 55-years-old. There are more than 60,000 new cases diagnosed annually in the US accounting for approximately 14,000 deaths1. In addition, there are an estimated 500,000 patients in the US with a history of bladder cancer which makes its prevalence greater than that of lung cancer2. Cigarette smoking is one of the most well known risk factors, increasing the risk 2-to-4 fold and is attributed to causing 50-66% of all bladder cancers in men3, 4. Unlike lung cancer, the risk for bladder cancer remains elevated for a long time after the member quits tobacco, which probably accounts for the rising incidence of disease noted in the past few decades1. Bladder cancer is much less common in the African American population than in Caucasians, who have the highest rate in the US population5.
Exposures to toxins such as in the textile dye and rubber tire industries are risk factors. Historically, these industries used β-naphthylamine, 4-aminobiphenyl, and benzidine all of which were unequivocally associated with bladder cancer. These chemicals have been banned, but the long delay between exposure and the development of malignancy makes it difficult to ascertain a definitive relationship for a whole host of other compounds which are still used in the chemical, dye and rubber industries3. Chronic infection can also be a risk factor for bladder cancer. This is seen more commonly in under-developed countries and thought to be largely related to infection with schistosomiasis6.
As with most cancers, prognosis is largely, but not entirely determined by stage and grade; other factors include location of the lesion in the bladder, number of lesions and maximum diameter of the largest tumor7. The American Joint Committee on Cancer staging system (also known as TNM) is the most widely used system for staging8 (see Table 2), while the World Health Organization and International Society of Urologic Pathologists published a recommended revised consensus classification system in 20049 (see Table 3). The upper urinary tract should be imaged during initial work up as 5% of bladder cancers can have an upper tract lesion10.
Urothelial carcinoma, also known as transitional cell carcinoma, is the most common pathologic subtype of bladder cancer and is seen in over 90% of all tumors. Squamous cell tumors account for about 5% of all cases and adenocarcinomas are about 1% of the total. The presenting symptom in the majority of cases is hematuria which can be either continuous or intermittent. Therefore, the American Urologic Association (AUA) recommended in 2001 that all patients with hematuria, particularly those without evidence of infections, stones or other common causes, undergo cystoscopy and upper tract imaging. The physical exam is unremarkable in bladder cancer patients, particularly those with nonmuscle invasive disease, (which accounts for 70% to 75% of patients)1. As our population is relatively young, most of the cases will be early in the lifecycle and more likely to be non-muscle-invasive in nature.
Table 1: American Joint Committee on Cancer Bladder Staging System8

Stage

Clinical Tumor Stage

TX

Tumor cannot be assessed

Ta

Non-invasive papillary carcinoma

Tis

Carcinoma in situ

T1

Tumor invades lamina propria

T2

Tumor invades muscularis propria

T2a

Invades superficial muscularis propria (inner half)

T2b

Invades deep muscularis propria (outer half)

T3

Tumor invades perivesical tissue/fat

T3a

Invades perivesical tissue/fat microscopically

T3b

Invades perivesical tissue/fat macroscopically (extravesical mass)

T4

Tumor invades prostate, uterus, vagina, pelvic wall, or abdominal wall

T4a

Invades adjacent organs (uterus, ovaries, prostate stroma)

T4b

Invades pelvic wall and/or abdominal wall




Regional Lymph Nodes (N)

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in a single lymph node, 2 cm or less in greatest dimension

N2

Metastasis in single lymph node, more than 2 cm but not more than 5 cm in greatest dimension; or multiple lymph nodes, none more than 5 cm in greatest dimension

N3

Metastasis in a lymph node more than 5 cm in greatest dimension




Distant Metastasis (M)

MX

Distant metastasis cannot be assessed

M0

No distant metastasis

M1

Distant metastasis


Table 2 – AJCC Stage Grouping for Bladder Cancer.8

Stage

Primary Tumor (pT)

Regional Lymph Nodes (N)

Distant Metastasis (M)

0a

Ta

N0

M0

0is

Tis

N0

M0

I

T1

N0

M0

II

T2a

N0

M0




T2b

N0

M0

III

T3a

N0

M0




T3b

N0

M0




T4a

N0

M0

IV

4b

N0

M0




Any T

N1

M0




Any T

N2

M0




Any T

N3

M0




Any T

Any N

M1


Table 3: WHO Grading Classification of Nonmuscle Invasive Urothelial Neoplasia9

Hyperplasia (flat and papillary)

Reactive atypia

Atypia of unknown significance

Urothelial dysplasia

Urothelial carcinoma in situ

Urothelial papilloma

Papillary urothelial neoplasm of low malignant potential

Nonmuscle invasive low-grade papillary urothelial carcinoma

Nonmuscle invasive high-grade papillary urothelial carcinoma

Treatment is largely dependent upon the grade and stage, with more invasive treatment as the grade and stage increase. Therapy can range from transurethral resection of a bladder tumor (TURBT) to radical cystectomy and resection of affected structures. Often, intravesical therapy is used as an adjunct to tumor resection and or as a prophylactic measure to prevent recurrence.


For non-muscle invasive tumors (defined as stages Ta, Tis, and T1), the initial treatment is a complete TURBT and an examination under anesthesia (EUA) to rule out a palpable mass which would suggest muscle invasive disease. For T1 tumors, up to 30% of cases will be understaged by TURBT, so repeat TURBT is recommended to decrease likelihood of actual understaging. The majority of these non-muscle invasive tumor cases will recur and up to 25% of these will progress, so rigorous surveillance and follow-up is mandatory11. Intravesical therapy (instilled into the bladder via catheter) is generally used in the adjuvant setting, to prevent further recurrence. Chemotherapy or immunotherapy agents can be used in this manner. Bacillus Calmette-Guérin (BCG) and mitomycin C are widely used as an intravesical immunotherapy agent but other agents can be used as well. A key point with these agents is that patients often have no side effects for several cycles, and then 90% will develop cystitis1, 4 and up to than 25% will develop fever, malaise, and hematuria4. These symptoms generally resolve quickly after completion of therapy, which is usually administered once/week for 6 weeks.
For tumors that are invasive (T2 and above) and for some high grade T1 tumors, radical cystectomy is the recommended therapy, with consideration of neoadjuvant chemotherapy and radiotherapy, depending on stage of disease at presentation and the patient’s overall health status. Bladder preservation or sparing treatment using primary chemotherapy and external beam radiotherapy is an option in selected patients with T2 and T3a urothelial carcinomas, but is associated with higher rates of recurrence and disease specific mortality. Often this approach is reserved for patients who are medically unfit for major surgery or for those seeking an alternative treatment course5.
Because of a fairly high risk of recurrence for all grades and stages, there will be a lifetime need for scheduled follow up evaluation. In general, all patients with non-invasive disease can expect a recurrence rate of 50%, but this rate is higher in those with high grade disease2. Follow up is recommended in accordance with American Urological Association (AUA) practice guidelines. Early after treatment, the patient may be required to undergo urologic evaluation (urinalysis, cytology, cystoscopy, +/- imaging and additional labs) every 3 months. After 2 years without recurrence, the recommendation is for annual exams indefinitely5. Several urothelial malignancy markers have recently been approved by the FDA, but there is not sufficient evidence at this time for their routine use in detection of new disease or surveillance for recurrence10, 12. However, studies are ongoing.
II. Aeromedical Concerns.
The aeromedical concerns are based more on the treatment and possible therapy complications than on the disease itself. If the aviator is off all treatment medications and is disease-free (considered to be in remission) and asymptomatic, he or she can be considered for a waiver. Due to a relatively high risk for recurrence, the flyer needs frequent follow up with their urologist. There is low likelihood that recurrence of non-invasive disease would cause sudden incapacitation.
III. Waiver Considerations.
History of bladder cancer is disqualifying for all flying classes in the US Air Force.
Table 4. Waiver potential of bladder cancer in FC I/IA, II and III.

Flying Class (FC)

Condition

Waiver Potential

Waiver Authority



ACS review/evaluation

I/IA

Stages 0 and I

Yes#†

AETC


Yes%

II

Stages 0, I, II and possibly early III

Yes+*†

AFMOA


Yes%

III

Stages 0, I, II and possibly early III

Yes+*†

MAJCOM


Yes%

# For FC I/IA individuals waiver may be considered after 5 years of remission, asymptomatic.

+ For trained FC II and III individuals waiver may be considered six months after treatment completed, in remission and asymptomatic.

* For untrained FC II and III, waiver may be considered after 5 years of remission.

† No indefinite waivers.

% ACS review needed only if waiver authority considering a waiver
Review of AIMWTS database in Jun 09 revealed 12 waiver requests. There was one FC I case which was actually an active duty navigator applying to UPT; he had a superficial tumor, but was disqualified due to the fact it was a FC I case. There were eight FC II cases and all were granted a waiver and three FC III cases, all granted a waiver. One of the FC III cases was for a young man who had a bladder rhabdomyosarcoma at age 2 and recovered well. The remaining 11 cases all appeared to be superficial tumors (not all discussed pathology).
IV. Information Required for Waiver Submission.
Aeromedical disposition and waiver submission should only be submitted after clinical disposition has been completed and all appropriate treatments have been initiated using best current clinical guidelines/recommendations.

Waiver can be considered once the aviator is asymptomatic from both the disease and therapy. The aeromedical summary for initial waiver for bladder cancer should include:


A. History – symptoms, pathology, stage, treatment, including date of last treatment, surveillance plan and activity level.

B. List and fully discuss all clinical diagnoses and diagnoses requiring a waiver.

C. Reports from all imaging studies.

D. All cystoscopy/surgical reports along with pathology-confirmed histological diagnosis.

E. Current urinalysis.

F. Urology/oncology consults to include the quarterly tumor surveillance follow-up in accordance with National Comprehensive Cancer Network (NCCN) guidelines.

G. Tumor board report, military or civilian, if applicable.

H. Medical evaluation board results.

I. Confirmation the aviator does not require continued therapy (other than routine follow-up) and that he or she is free of physical limitations.

The aeromedical summary for waiver renewal for bladder cancer should include the following:


A. History – brief summary of stage, treatment, frequency of surveillance and results, any symptoms, activity level; all must be consistent with NCCN guidelines.

B. Physical – pertinent to present case.

C. Urology/oncology consult.

D. Labs – all urinalysis and cystoscopy results since last waiver.




ICD9 Codes for Bladder Cancer

188

Malignant neoplasm of bladder

233.7

Carcinoma in situ of bladder


Waiver Guide reviewed by the AF/SG Consultant for Urology, Lt Col Edith Canby-Hagino.
V. References.
1. Hall MC, Chang SS, Dalbagni G, et al., Guideline for the management of nonmuscle invasive bladder cancer (stages Ta, T1, and Tis): 2007 update. J Urol, 2007; 178(6):2314-30.
2. Grossman HB, Soloway M, Messing E, et al. Surveillance for Recurrent Bladder Cancer Using a Point-of-Care Proteomic Assay. JAMA, 2006; 293(3):299-305.
3. Kirkali Z, Chan T, Manoharan M, et al., Bladder cancer: epidemiology, staging and grading, and diagnosis. Urology, 2005; 66(6 Suppl 1): p. 4-34.
4. Pashos CL, Botteman MF, Laskin BL, and Redaelli A. Bladder cancer: epidemiology, diagnosis, and management. Cancer Pract, 2002; 10(6):311-22.
5. Montie JE, Clark PE, Eisenberger MA, et. al. Bladder Cancer, in Practice Guidelines in Oncology,. 2009, National Comprehensive Cancer Network.
6. Badawi AF, Mostafa MH, Probert A, and O’Connor PJ. Role of schistosomiasis in human bladder cancer: evidence of association, aetiological factors, and basic mechanisms of carcinogenesis. Eur J Cancer Prev, 1995; 4(1):45-59.
7. Parmar MK. Prognostic factors for recurrence and follow-up policies in the treatment of superficial bladder cancer: report from the British Medical Research Council Subgroup on Superficial Bladder Cancer (Urological Cancer Working Party). J Urol, 1989; 142(2 Pt 1):284-8.
8. Greene FL, Page DL, Fleming ID, et. al. AJCC Cancer Staging Manual. 6th ed. 2002, New York: Springer-Verlag.
9. Eble JN, Sauter G, Epstein JI, and Sesterhenn IA. World Health Organization Classification of Tomours: Pathology and Genetics of Tomours of the Urinary and Male Genital Organs, 2004, Lyon.
10. Morey SS. American Urological Association issues guidelines on the management of bladder cancer. Am Fam Physician, 2000; 61(12): 3734, 3736.
11. O’Donnell MA. Treatment of non-muscle-invasive (superficial) bladder cancer. UpToDate. Online version 16.3, 1 October, 2008.
12. American Urological Association, Hematuria, in Medical Student Curriculum, A.U. Association, Editor, 2008.

WAIVER GUIDE



Updated: Jun 09

Supersedes Waiver Guide of Mar 99

By: Col Brett Wyrick (RAM 09B) and Dr Dan Van Syoc
CONDITION:



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