Statement of Principles
concerning
 
MALIGNANT NEOPLASM OF THE BREAST
No. 97 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 breast No. 97 of 2014.
Determination
2.         The Repatriation Medical Authority under subsection 196B(3) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a)        revokes Instrument No. 28 of 2006 concerning malignant neoplasm of the breast; and
(b)        determines in its place this Statement of Principles.
Kind of injury, disease or death
3.         (a)        This Statement of Principles is about malignant neoplasm of the breast and death from malignant neoplasm of the breast.
(b)               For the purposes of this Statement of Principles, "malignant neoplasm of the breast" means a primary malignant neoplasm arising from the cells of the breast, including carcinoma in situ.  This definition excludes soft tissue sarcoma, carcinoid tumour, non-Hodgkin’s lymphoma and Hodgkin’s lymphoma.
(c)                Malignant neoplasm of the breast attracts ICD-10-AM code C50 or D05.
(d)       In the application of this Statement of Principles, the definition of "malignant neoplasm of the breast" is that given at paragraph 3(b) above.
Basis for determining the factors
4.         On the sound medical-scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that malignant neoplasm of the breast and death from malignant neoplasm of the breast can be related to relevant service rendered by veterans 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 exist before it can be said that, on the balance of probabilities, malignant neoplasm of the breast or death from malignant neoplasm of the breast is connected with the circumstances of a person’s relevant service is:
(a)               having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the breast at least ten years before the clinical onset of malignant neoplasm of the breast; or
(b)               using hormone replacement therapy for at least two years before the clinical onset of malignant neoplasm of the breast, and where the use of hormone replacement therapy has ceased, the clinical onset of malignant neoplasm of the breast has occurred within five years of cessation; or
(c)               using a combined oral contraceptive pill for a continuous period of at least three years where:
(i)            use of the combined oral contraceptive pill commenced at least five years before the clinical onset of malignant neoplasm of the breast; and
(ii)          where use of the combined oral contraceptive pill has ceased, the clinical onset of malignant neoplasm of the breast has occurred within ten years of cessation; or
(d)              breast feeding for a cumulative period of less than three months before the clinical onset of malignant neoplasm of the breast; or
(e)               for females aged over 35 years only, being nulliparous at the time of the clinical onset of malignant neoplasm of the breast; or
(f)                being pregnant within the ten years before the clinical onset of malignant neoplasm of the breast; or
(g)               having a first live birth after the age of 30 years or having a first full-term pregnancy after the age of 30 years, within the 30 years before the clinical onset of malignant neoplasm of the breast; or
(h)               drinking at least 80 kilograms of alcohol within the 20 years before the clinical onset of malignant neoplasm of the breast; or
(i)                 an inability to undertake any physical activity greater than three METs for at least 20 years within the 30 years before the clinical onset of malignant neoplasm of the breast; or
(j)                 for death from malignant neoplasm of the breast only, being prevented from accessing mammographic screening for malignant neoplasm of the breast in accordance with contemporary medical standards at the time, within the ten years before the clinical onset of malignant neoplasm of the breast, and where:
(i)            if mammographic screening has been resumed in the interim, there has been no normal test result; and
(ii)          the opportunity for subsequent appropriate mammographic screening has not been declined; or
(k)               for males and postmenopausal females only:
(i)            being obese for at least ten years within the 20 years before the clinical onset of malignant neoplasm of the breast; or
(ii)          having diabetes mellitus before the clinical onset of malignant neoplasm of the breast; or
(l)                 using digoxin for a continuous period of at least one year before the clinical onset of malignant neoplasm of the breast, and where use of digoxin has ceased, the clinical onset of malignant neoplasm of the breast has occurred within five years of cessation; or
(m)             being administered diethylstilbestrol while pregnant within the thirty years before the clinical onset of malignant neoplasm of the breast; or
(n)               inability to obtain appropriate clinical management for malignant neoplasm of the breast.
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 breast where the person’s malignant neoplasm of the breast 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;
"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;
"combined oral contraceptive pill" means an oral contraceptive compound containing both oestrogen and progestogen;
"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 breast" 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 breast;
"hormone replacement therapy" means administration of oestrogen preparations often in combination with progesterone to offset a hormone deficiency following surgically induced or naturally occurring menopause;
"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;
"MET" means a unit of measurement of the level of physical exertion.  1 MET = 3.5 ml of oxygen/kg of body weight per minute, 1.0 kcal/kg of body weight per hour or resting metabolic rate;
"nulliparous" means having never given birth to a viable infant;
"relevant service" means:
(a)        eligible war service (other than operational service) under the VEA;
(b)        defence service (other than hazardous service and British nuclear test defence service) under the VEA; or
(c)        peacetime 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 120B of the VEA or section 339 of the MRCA applies.
Date of effect
11.       This Instrument takes effect from 17 November 2014.
Dated this   seventeenth   day of   October   2014
The Common Seal of the                    )
Repatriation Medical Authority          )
was affixed at the direction of:          )
PROFESSOR NICHOLAS SAUNDERS AO
CHAIRPERSON