Guidance for Considerations in Rating Impairment from Industrial Cancer
Doctors performing a medical-legal evaluation for purposes of a workers’ compensation case must examine for and report all rateable impairments resulting from an illness or injury, including cancer, and/or from the effects of treatment for such cancer. The purpose of this form is to provide physicians with additional guidance concerning the types of impacts and impairments that injured workers who have been diagnosed with and treated for cancer may experience. Practitioners are reminded that an appropriate rating under the Guides for any form of cancer should take into account all impairments, including those caused by cancer treatment, found through a full and thorough medical evaluation. (If a practitioner is unable to evaluate or to rate an impairment because it is outside their scope of practice and area of clinical competence, they should advise the parties accordingly so they may obtain any necessary additional evaluations.)
The DWC’s goal is to ensure that all impairment related to industrial cancer is rated adequately and appropriately. In assessing impairment related to any industrial cancer, the evaluating physician should consider the following, among any other factors that apply based on the medical evaluation:
- The body part or organ where the cancer originated, the impact to that body part, and the impact of damage to that body part on the injured worker’s systemic health;
- Any impact on body parts other than where the cancer originated;
- The permanent impact from any surgical treatment for the cancer, including the impacts from any removal of body parts, scarring, limitations of range of motion and/or strength caused by the surgery, nerve damage, and any residual or permanent pain resulting from the surgery;
- The permanent impact from any chemotherapy, including any nerve damage, organ damage, or loss of reproductive capacity, among other potential impacts;
- The permanent impact from any radiation, including scarring or skin damage;
- And the permanent impact of any long-term medications that are taken by the injured worker either to prevent recurrence of the cancer, or to prevent any advancement or spreading of malignancies.
- Surgical treatment may involve removal of the breast(s) (mastectomy). This may be given 0-5% whole person impairment per the AMA Guides, page 239.
- Surgical treatment may result in skin disfigurement. Physicians may assess this type of impairment under the AMA Guides, sections 8.2 and 8.3, pages 175-76, and as illustrated in the AMA Guides, Table 8-2, on page 178.
- Surgical treatment of breast cancer may also result in loss of upper extremity function. Assessment of loss of upper extremity function may include:
- Decreased range of motion in upper extremity, including shoulder joint, which may be evaluated under range of motion charts in AMA Guides chapter 16, and/or reduction in upper extremity strength, which may be evaluated per Table 16-35. This may result from surgical incisions, scarring, skin and tissue removal, tightening of remaining skin and muscle, and related issues.
- Neurologic impairment of the upper extremity nerves, which may be evaluated utilizing the AMA Guides. Tables 16-13, 16-14 or 16-15 are used to identify maximum values of affected nerves. Tables 16-10 or 16-11 are used to assess the percentage of motor or nerve deficit of affected nerves. Neurologic impairment is calculated per the AMA Guides instructions, section 16.5 on pages 480-95.
- The removal of lymph nodes in the treatment of breast cancer may cause lymphedema (swelling) in the arms for some patients. If so, the physician should use AMA Guides chapter 16 to assess function impairment such as decreased range of motion and strength loss in the upper extremity. Pain related to swelling may be rated (see #8 below). Upper extremity strength impairment may be evaluated per AMA Guides Table 16-35.
- Breast cancer treatment may involve the prescription and long-term use of hormone therapy (e.g., Tamoxifen) and/or aromatase inhibitors (e.g., Anastrozole (Arimidex), Exemestane (Aromasin), Letrozole (Femara).) These medications may have side effects causing impairment, including joint pain (see the range of motion tables in AMA Guides chapters 16 and 17 if range of motion is affected), menopausal symptoms (see AMA Guides Tables 7-9, 7-10, 7-11), and loss of bone density. Impairment resulting from these medications may be evaluated under appropriate AMA Guides tables, including those indicated above, or the physician may consider 1-3% WP impairment for effects of medication per AMA Guides, pages 20 and 600.
- Breast cancer treated with chemotherapy may result in chemotherapy-induced amenorrhea, loss of ovarian function and premature menopause. Impairment of this nature may be assessed utilizing the AMA Guides, section 7.8, on pages 163-169 (depending on impairment class, 0-35 percent WPI). Chemotherapy may also cause a number of other side-effects, some of which may be permanent, such as anemia (AMA guides Table 9-2), kidney damage (AMA Guides section 7.3), increased bleeding (AMA Guides Table 9-4), loss of taste (AMA Guides page 262 1-5 WPI), or reproductive impairments (AMA Guides Tables 7-9., 7-10, 7-11). As part of the evaluation, the physician should discuss any long-term impact of chemotherapy with the injured worker, and review literature as necessary concerning the known impacts of particular chemotherapies.
- Radiation treatment for breast cancer may cause scarring or other skin impairment. Physicians may assess this type of impairment under the AMA Guides, sections 8.2 and 8.3, pages 175-76, and as illustrated in the AMA Guides, Table 8-2, on page 178.
- For chronic pain related to breast cancer, its treatment or resulting lymphedema, a pain add-on of up to 3% WPI per PDRS page 1-12 may be considered. Also, the physician may consider any AMA Guides table, chapter or method to assess chronic pain in accordance with the Almaraz/Guzman decision. The Almaraz/Guzman decision allows the physician to use any chapter or table in the AMA Guides that they believe most accurately reflects the impairment. The opinion must set forth the physician’s facts and reasoning which justify their use of a particular chapter or table in order to be considered substantial evidence.
- Any other impairments identified by the physician related to the breast cancer or its treatment may be assessed using the appropriate AMA Guides impairment table, and the doctor may consider any table within the Guides to provide an accurate assessment of total impairment per the Almaraz/Guzman decision.
When rating medical reports involving breast cancer, the DEU rater should assess whether the reporting physician has considered all areas of potential impairment related to the breast cancer and its treatment. If it appears that the physician has failed to address any areas of potential impairment, the DEU rater should annotate the case, noting each of the areas of potential impairment as listed above that have not been addressed by the physician.
The following are examples of ratings that take into account the various considerations outlined above.
- A 48 year-old female police officer suffers from breast cancer which requires chemotherapy and bilateral mastectomy. The surgical removal of the breasts rates at 5% WPI. This is only one of the many factors that apply. She experiences chemotherapy-induced menopause (28% WPI) and bladder impairment (12% WPI). The combination of these particular impairments will result in a combined WPI of 40%. The resulting permanent disability rating for this impairment is set forth below.
DEU Rating Example - 48 year old female police officer
Bilateral mastectomy: 5 WP
10.00.00.99 – 5 – [1.4]7 – 490F – 7 – 8 PD
Ovarian Disease Class 3 (chemically induced menopause): 28 WP
07.05.00.00 – 28 – [1.4]39 – 490F – 39 – 43 PD
Bladder Impairment class 2: 12 WP
07.03.00.00 – 12 – [1.4]17 – 490H – 21 – 24 PD
43 C 24 C 8 = 60% Final PD
Rater annotation: The physician may consider cosmetic impairment as a result of mastectomy under AMA guides chapter 8 Table 8-2. The physician may also consider pain add-on of up to 3% WP for excess pain that effects activities of daily living.
- A 38 year-old female firefighter suffers from breast cancer that results in a single mastectomy. The loss of breast may constitute a WPI rating of 3% under the Guides. She suffers from loss of shoulder motion, which may rate at 4% WPI, and skin disfigurement as a result of the loss of the breast which results in 9% WPI. She experiences significant residual pain as a result of the mastectomy, resulting in an additional 3% WPI. The combination of these particular impairments will result in a combined WPI of 19%. The resulting permanent disability rating for this impairment is set forth below.
DEU Rating Example - 38 year old female firefighter
Mastectomy: 3 WP
10.00.00.99 – 6 – [1.4]8 – 490F – 8 – 8 PD
3 WP add-on included for pain
Left shoulder ROM S: 140-0-30 F: 140-0-40 R: 50-0-70: 7 UE = 4 WP
16.02.01.00 – 4 – [1.4]6 – 490I – 9 – 9 PD
Skin class I: 9 WP
08.01.00.00 – 9 – [1.4]13 – 490J – 20 – 20 PD
20 C 9 C 8 = 33 % Final PD
Checklist for Physicians Evaluating Breast Cancer Impairment – Or Impairment From Any Other Industrial Cancer -- and Assignment of Permanent Disability Numbers.
- Does the injury involve removal of a breast? If so per AMA Guides section 10.9a, page 239, physician should consider up to 5% whole person impairment. [For other cancers, consider the immediate impact on other body parts of any surgeries.]
Disability Evaluator should rate impairment under disability number 10.00.00.99 and adjust for FEC (1.4 modifier), occupation and age
- Was there surgical treatment that resulted in skin disfigurement? If so, this impairment may be under AMA Guides sections 8.2 and 8.3 and impairment assigned per Table 8-2.
Disability Evaluator should rate impairment under disability number 08.01.00.00 and adjust for FEC (1.4 modifier), occupation and age
- Did the surgical treatment result in range of motion impacts? (For breast cancer, consider reduction of shoulder or other upper extremity motion.) If so, physician may evaluate per AMA Guides section 16.4i and impairment assigned per Figures 16-40, 16-43 and 16-46.
Disability Evaluator should rate impairment under disability number 16.02.01.00 and adjust for FEC (1.4 modifier), occupation and age
- Did the surgical treatment result in loss of muscle strength? (For breast cancer, consider whether surgery resulted in loss of upper extremity strength. If so, physician may evaluate upper extremity strength loss per AMA Guides section 16.8.) Strength impairment is assessed per AMA Guides Table 16-35. Strength impairment would not be rated if the loss of strength is caused by decreased motion or pain.
Disability Evaluator should rate impairment under disability number 16.02.02.00 and adjust for FEC (1.4 modifier), occupation and age
- Did the surgical treatment, if any, result in neurologic impairment? (For breast cancer, consider impairment to the upper extremity nerves.) Neurological impairment may be evaluated utilizing the AMA Guides section 16.5 and Tables 16-13, 16-14 or 16-15, to identify maximum values of affected nerves, and Tables 16-10 or 16-11, to assess percentage of motor or nerve deficit of affected nerves. Decreased motion or strength as a result of neurological impairment would be encompassed and therefore not rated separately.
Disability Evaluator should rate impairment under disability number 16.01.02.03 or 16.01.02.01 and adjust for FEC (1.4 modifier), occupation and age
- Was there any chemotherapy treatment, and if so, were there any permanent impacts? (For breast cancer, consider whether chemotherapy resulted in amenorrhea, loss of ovarian function and premature menopause.) Impairment of this nature may be evaluated utilizing the AMA Guides, section 7.8, on pages 163-169 and impairment assigned per tables 7-9 or 7-11.
Disability Evaluator should rate impairment under disability number 07.05.00.00 and adjust for FEC (1.4 modifier), occupation and age
- Was there any radiation treatment, and if so, were there any permanent impacts from the radiation? (For breast cancer, consider whether there was any scarring or other skin disfigurement.)
- Is the injured worker taking any long-term medications to prevent recurrence or advancement of cancer, and if so, are there any ratable impacts from those medications? (For breast cancer, consider whether the use of Tamoxifen or aromatase inhibitors has any impacts, including joint pain.) Impairment due to side effects of medication may be evaluated per appropriate AMA Guides section and table related to side effect. If there is no applicable AMA Guides table that reflects impairment due to the side effect of medication, per AMA Guides 600, a side effect due to medication may receive a rating of 1-3% WP impairment.
Disability Evaluator should rate impairment under disability number related to the side effect and adjust for FEC (1.4 modifier), occupation and age
- Does the injured worker have any chronic pain related to the cancer and/or its treatment? A physician may consider a pain add-on of up to 3% WP per PDRS page 1-12 for pain.
Disability Evaluator should add pain impairment to disability related to the pain and adjust overall whole person impairment for that body part for FEC (1.4 modifier), occupation and age
Final note to Disability Evaluator: In reviewing the medical report, if it appears that the physician has failed to consider one or more of the areas of potential impairment as listed above, the rating should be annotated accordingly so that parties may follow up with the physician on that issue. The Disability Evaluator may then issue an amended rating based on any additional information received.
QME Complaint Form
QME Physicians: Please remember to inform injured workers that the DWC takes complaints about QMEs and that a complaint form can be found on the DWC website.