Statement of Principles concerning   MALIGNANT NEOPLASM OF THE BREAST No. 27 of 2006   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. 27 of 2006.   Determination 2.                  The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA): (a)       revokes Instrument No. 53 of 1997 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 codes 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.         The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that malignant neoplasm of the breast and death from malignant neoplasm of the breast 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 breast or death from malignant neoplasm of the breast with the circumstances of a person’s relevant service is:   (a)               having received a cumulative equivalent dose of at least 0.05 Sievert of atomic radiation to the affected breast where this dose was accumulated at least five years before the clinical onset of malignant neoplasm of the breast; or   (b)              having received a course of therapeutic radiation to the chest at least five years before the clinical onset of malignant neoplasm of the breast; or   (c)              having received a cumulative equivalent dose of at least 0.05 Sievert of diagnostic radiation to the affected breast where this dose was accumulated at least five years before the clinical onset of malignant neoplasm of the breast; or   (d)              having 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 ten years of that period; or   (e)              ingesting a combined oral contraceptive pill for a continuous period of at least three years within the 15 years before the clinical onset of malignant neoplasm of the breast; or   (f)               for females only, breast feeding for less than six months before the clinical onset of malignant neoplasm of the breast; or   (g)              for females over the age of 30 years only, being nulliparous at the time of the clinical onset of malignant neoplasm of the breast; or   (h)              having a first live birth after the age of 30 years or having a first full-term pregnancy after the age of 30 years, before the clinical onset of malignant neoplasm of the breast; or   (i)                drinking at least 80 kilograms of alcohol within a period of 15 years within the 20 years before the clinical onset of malignant neoplasm of the breast; or   (j)                for males and postmenopausal females only, being obese for a period of at least three years within the ten years before the clinical onset of malignant neoplasm of the breast; or   (k)              an inability to undertake any physical activity greater than three METs for at least ten years within the 30 years before the clinical onset of malignant neoplasm of the breast; or   (l)                inability to obtain appropriate clinical management for malignant neoplasm of the breast.   Factors that apply only to material contribution or aggravation 7.         Paragraph 6(l) 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:   “a course of therapeutic radiation” means one or more fractions (treatment portions) of ionising radiation administered with the aim of achieving palliation or cure with gamma rays, x-rays, alpha particles or beta particles;   “alcohol” is measured by the alcohol consumption calculations utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink;   “atomic radiation” means ionising radiation excluding: (a)           natural background radiation; (b)           therapeutic radiation; and (c)           radiation from diagnostic procedures;   “being obese” means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of thirty 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 contraceptive pills containing oestrogen and progestogen;   “cumulative equivalent dose” means the total equivalent dose of radiation from all types of ionising radiation.  It accounts for the differences in biological effectiveness of various types of radiation and allows doses from different radiations to be combined. Each component is calculated by multiplying the absorbed dose in a particular tissue or organ for a given type of radiation by the radiation weighting factor for that radiation.  The unit of equivalent dose is the Sievert;   “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 hormonal preparations (e.g. oestrogen and/or progestogen) to combat a hormone deficiency due to 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), Fourth Edition, effective date of 1 July 2004, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 1 86487 594 1;   “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 or, 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)     operational service under the VEA; (b)     peacekeeping service under the VEA; (a)          hazardous service under the VEA; (b)          warlike service under the MRCA; or (c)          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 28 June 2006.   Dated this   nineteenth         day of              June  2006     The Common Seal of the                              ) Repatriation Medical Authority                   ) was affixed to this instrument                      ) in the presence of:                                        )   KEN DONALD CHAIRPERSON