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New Rules For Evaluating Breast Cancer in Social Security Claims
By Pitt Dickey

Breast cancer. Two words no one ever wants to hear. Life is going along with its usual path. Suddenly there is a mountain up ahead to climb. A diagnosis of breast cancer. On first view, the mountain may appear unclimbable. But the good news is that you don't have to climb it alone. Like Sir Edmund Hillary had his Sherpa, Tensing Norgay, to help him climb Mount Everest, breast cancer patients have a large number of Sherpas to help them climb the mountain that suddenly appeared in their lives. Most of these Sherpas are medical personnel, doctors, surgeons, nurses, and oncologists. They speak a different language from the patient. They will talk about biopsies, positive and negative nodes, reconstructive surgery, surgical margins, chemotherapy and radiation therapy. Their language is that of fighting and healing breast cancer. It sounds spooky and foreign but it is the language of hope. They know what they are doing in helping the patient climb her mountain.

In addition to the medical Sherpas, the Social Security Administration (SSA) also can help women get through this difficult period. Just because you have breast cancer doesn't mean that your normal bills stop. They continue along with new medical expenses. A woman who is disabled by breast cancer can receive SSA Disability Insurance Benefits to help with her financial expenses if her condition is such that she cannot work. The Disability Insurance Benefits from the SSA are payable if the SSA determines that the woman has a medical condition that prevents her from being able to work for at least twelve months. The SSA will begin using new rules on 15 December 2004 to evaluate Disability Insurance claims which involve patients who are fighting cancer. The rules are very extensive and make substantial changes in the evaluation of all disability claims based on cancer. This column will briefly review the new rules in general, and specifically as to how they impact SSA Disability Insurance claims from breast cancer patients.

If a person already has been awarded disability benefits due to breast cancer under Social Security, the SSA will not re-evaluate that person's disability claim under the new rules. If the person is having her earlier disability claim evaluated by the SSA under a continuing disability review, the old set of rules will continue to be used by the SSA.

When the SSA evaluates cancer claims it considers such factors as: 1. The origin of the malignancy; 2. The extent of involvement; 3. The duration, frequency, and response to therapy used to treat the cancer. The SSA uses the term "antineoplastic therapy" to describe cancer treatments which cover "surgery, irradiation, chemotherapy, hormones, immunotherapy, bone marrow or stem cell transplantation." The SSA will require medical records which specify the type of cancer, where it is located, and if it has spread from its original site to other parts of the body. If the cancer is spread it is said to have become metastatic.

In breast cancer, if the cancer has remains in the breast alone and has not spread into other parts of the body such as lymph nodes, it has not become metastatic. In all cases the SSA will requires information as to the patient's response to the antineoplastic therapy. A breast cancer patient might have surgery followed by chemotherapy or radiation or chemotherapy followed by surgery. If the patient has a variety of treatments such as surgery, chemotherapy and radiation, the SSA may need to wait to see if the treatment has been effective before making a decision. However the SSA can make a fully favorable decision in favor of granting the disability benefits without waiting for the results of the treatment to be known if the patient's claim warrants an earlier favorable decision.

The SSA, in addition to considering the direct effects of the breast cancer, will also consider the effects of the therapy on the patient. The SSA recognizes that the side effects of chemotherapy and radiation can be disabling in themselves. The SSA will need medical documentation of the drugs given, frequency of drug treatment, schedule and fields of radiation therapy and extent of the surgery. Complications resulting from the therapy will be needed to include any continuing gastrointestinal symptoms, persistent weakness, neurological complications, cardiovascular complications or reactive mental disorders such as depression.

If the breast cancer has spread to other locations in the patient's body the SSA will usually want medical records of at least three months in duration after the start of therapy to treat the cancer to see if the treatment is going to be successful. The SSA recognizes that chemotherapy and radiation can be temporarily disabling but cannot pay for temporary disability. For the SSA to be able to pay Disability Insurance benefits, the SSA must be able to determine that the patient's condition will prevent her from being able to work at least twelve months.

The SSA new listing for evaluating breast cancer claims establishes that a claimant meets the medical requirement for awarding disability in cases where the patient has locally advanced cancer such as inflammatory cancer, a tumor of any size with direct extension to the chest wall, or skin, or a tumor of any size with metastases to the ipsilateral internal mammary nodes; or which has distant metastases; or recurrent carcinoma except in cases with a local recurrence of the cancer that can be successfully treated with antineoplastic therapy such as surgery, radiation, or chemotherapy.

In addition to meeting or equaling the medical listing for cancer, the patient must also not be performing work that pays enough to be considered by the SSA to be substantial gainful activity. To begin the process of applying for Social Security Disability benefits, the person needs to contact their local Social Security Disability District Office and request the forms for filing the disability claim.

The patient is not facing this mountain alone, the medical Sherpas and the Social Security Sherpas are there to help her through the this trying time. Remember what N.C. State Coach Jimmy Valvano said, "Don't ever, ever give up." Medical science has made outstanding progress in the area of breast cancer. For further information contact the American Cancer Society at 919-834-8463 at 11 S. Boylan Avenue, Raleigh, N.C. 27603 or on line at www.cancer.org.