Statement of Principles
concerning
 
MALIGNANT NEOPLASM OF THE STOMACH
No. 58 of 2014
 
for the purposes of the
 
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
Title
1.         This Instrument may be cited as Statement of Principles concerning malignant neoplasm of the stomach No. 58 of 2014.
Determination
2.         The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a)        revokes Instrument No. 7 of 2003, as amended by Instrument No. 65 of 2011, concerning malignant neoplasm of the stomach; and
(b)        determines in their place this Statement of Principles.
Kind of injury, disease or death
3.         (a)        This Statement of Principles is about malignant neoplasm of the stomach and death from malignant neoplasm of the stomach.
(b)               For the purposes of this Statement of Principles, "malignant neoplasm of the stomach" means a primary malignant neoplasm arising from the epithelial cells of the stomach.  Anatomically the stomach is defined as extending from the lower border of the oesophageal sphincter, to, and including, the pyloric sphincter.  This definition of malignant neoplasm of the stomach excludes soft tissue sarcoma, carcinoid tumour, non-Hodgkin’s lymphoma and Hodgkin’s lymphoma.
(c)                Malignant neoplasm of the stomach attracts ICD-10-AM code C16.
(d)               In the application of this Statement of Principles, the definition of "malignant neoplasm of the stomach" is that given at paragraph 3(b) above.
Basis for determining the factors
4.         The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that malignant neoplasm of the stomach and death from malignant neoplasm of the stomach can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
Factors that must be related to service
5.         Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
Factors
6.         The factor that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting malignant neoplasm of the stomach or death from malignant neoplasm of the stomach with the circumstances of a person’s relevant service is:
(a)                smoking at least 15 pack-years of cigarettes, or the equivalent thereof in other tobacco products, where smoking commenced at least 15 years before the clinical onset of malignant neoplasm of the stomach, and where smoking has ceased, the clinical onset of malignant neoplasm of the stomach has occurred within 25 years of cessation; or
(b)                having received a cumulative equivalent dose of at least 0.1 sievert of ionising radiation to the stomach at least five years before the clinical onset of malignant neoplasm of the stomach; or
(c)                for non-cardia gastric carcinoma only:
(i)           being infected with Helicobacter pylori at least ten years before the clinical onset of malignant neoplasm of the stomach; or
(ii)         having undergone a partial gastrectomy at least 15 years before the clinical onset of malignant neoplasm of the stomach; or
(iii)       drinking at least 100 kilograms of alcohol within the five years before the clinical onset of malignant neoplasm of the stomach; or
(d)               having chronic atrophic gastritis, where the chronic atrophic gastritis commenced at least five years before the clinical onset of malignant neoplasm of the stomach; or
(e)                an inability to consume an average of at least 200 grams per day of any combination of allium vegetables and fresh fruits, for at least five years within the 25 years before the clinical onset of malignant neoplasm of the stomach; or
(f)                 having at least daily consumption of preserved vegetables for at least five years within the 25 years before the clinical onset of malignant neoplasm of the stomach; or
(g)                consuming an average daily intake of at least 25 grams per day of processed meat product, for at least ten years within the 25 years before the clinical onset of malignant neoplasm of the stomach; or
(h)                having at least weekly consumption of Chinese-style salted fish for at least five years within the 25 years before the clinical onset of malignant neoplasm of the stomach; or
(i)                  having at least daily consumption of fermented soy products for at least five years within the 25 years before the clinical onset of malignant neoplasm of the stomach; or
(j)                  taking tamoxifen daily for at least the one year before the clinical onset of malignant neoplasm of the stomach; or
(k)                being obese for at least the five years before the clinical onset of malignant neoplasm of the stomach; or
(l)                  inhaling respirable asbestos fibres in an enclosed space:
(i)            for a cumulative period of at least 1 000 hours before the clinical onset of malignant neoplasm of the stomach; and
(ii)          at the time material containing respirable asbestos fibres was being applied, removed, dislodged, cut or drilled; and
(iii)        the first inhalation of respirable asbestos fibres commenced at least five years before the clinical onset of malignant neoplasm of the stomach; or
(m)              inhaling respirable asbestos fibres in an open environment:
(i)           for a cumulative period of at least 3 000 hours before the clinical onset of malignant neoplasm of the stomach; and
(ii)         at the time material containing respirable asbestos fibres was being applied, removed, dislodged, cut or drilled; and
(iii)       the first inhalation of respirable asbestos fibres commenced at least five years before the clinical onset of malignant neoplasm of the stomach; or
(n)                inability to obtain appropriate clinical management for malignant neoplasm of the stomach.
Factors that apply only to material contribution or aggravation
7.         Paragraph 6(n) applies only to material contribution to, or aggravation of, malignant neoplasm of the stomach where the person’s malignant neoplasm of the stomach was suffered or contracted before or during (but not arising out of) the person’s relevant service.
Inclusion of Statements of Principles
8.         In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
Other definitions
9.         For the purposes of this Statement of Principles:
"alcohol" is measured by the alcohol consumption calculations utilising the Australian Standard of ten grams of alcohol per standard alcoholic drink;
"allium vegetables" means raw or cooked, but not preserved, bulbous plants belonging to the genus Allium and includes garlic, leek, onion, chives and shallots;
"being obese" means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of 30 or greater.
The BMI = W/H2 and where:
W is the person’s weight in kilograms; and
H is the person’s height in metres;
"Chinese-style salted fish" means fish preserved by salting and is characterised by using less salt and a higher degree of fermentation during the drying process than other methods because of the relatively high outdoor temperature and moisture levels.  Chinese-style salted fish is a traditional part of the diet in southern China, Hong Kong, Taiwan, Malaysia, Singapore and other areas of south-east Asia;
"chronic atrophic gastritis" means inflammation of the gastric mucosa characterised by variable gland loss and inflammatory infiltrate extending below the lamina propria with distortion and destruction of the gastric glands;
"cumulative equivalent dose" means the total dose of ionising radiation received by the particular organ or tissue.  The formula used to calculate the cumulative equivalent dose allows doses from multiple types of ionising radiation to be combined, by accounting for their differing biological effect. The unit of equivalent dose is the sievert.  For the purposes of this Statement of Principles, the calculation of cumulative equivalent dose excludes doses received from normal background radiation, but includes therapeutic radiation, diagnostic radiation, cosmic radiation at high altitude, radiation from occupation related sources and radiation from nuclear explosions or accidents;
"death from malignant neoplasm of the stomach" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s malignant neoplasm of the stomach;
"fermented soy products" means food and food additives made from fermented soybeans, examples include naturally brewed soy sauce, tamari, pickled tofu, miso, fermented bean paste, yellow soybean paste and tempeh;
"ICD-10-AM code" means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Eighth Edition, effective date of 1 July 2013, copyrighted by the Independent Hospital Pricing Authority, and having ISBN 978-1-74128-213-9;
"non-cardia gastric carcinoma" means a carcinoma that has arisen in the mucosa of any part of the stomach, excluding that part of the stomach immediately adjacent to and surrounding the opening of the oesophagus (the cardia of the stomach) that is distinguished histologically by the presence of cardiac glands and the absence of parietal (acid secreting) and chief (pepsin secreting) cells;
"pack-years of cigarettes, or the equivalent thereof in other tobacco products" means a calculation of consumption where one pack-year of cigarettes equals twenty tailor-made cigarettes per day for a period of one calendar year, or 7 300 cigarettes.  One tailor-made cigarette approximates one gram of tobacco or one gram of cigar or pipe tobacco by weight.  One pack-year of tailor-made cigarettes equates to 7.3 kilograms of smoking tobacco by weight.  Tobacco products mean cigarettes, pipe tobacco or cigars, smoked alone or in any combination;
"preserved vegetables" means vegetables preserved by salting, fermenting or pickling;
"processed meat product" means preserved or cured meats, including ham, frankfurters, salami and bacon;
"relevant service" means:
(a)                operational service under the VEA;
(b)                peacekeeping service under the VEA;
(c)                hazardous service under the VEA;
(d)               British nuclear test defence service under the VEA;
(e)                warlike service under the MRCA; or
(f)                 non-warlike service under the MRCA;
"terminal event" means the proximate or ultimate cause of death and includes:
(a)                pneumonia;
(b)               respiratory failure;
(c)                cardiac arrest;
(d)               circulatory failure; or
(e)                cessation of brain function.
Application
10.       This Instrument applies to all matters to which section 120A of the VEA or section 338 of the MRCA applies.
Date of effect
11.       This Instrument takes effect from 2 July 2014.
Dated this  twentieth   day of   June   2014
The Common Seal of the                    )
Repatriation Medical Authority          )
was affixed at the direction of:          )
PROFESSOR NICHOLAS SAUNDERS AO
CHAIRPERSON