Program Operations Manual System (POMS)
TN 1 (10-08)
DI 23022.125 Breast Cancer
COMPASSIONATE ALLOWANCE INFORMATION
Breast cancer forms in tissues of the breast, usually the ducts and lobules. It occurs in both men and women, although male breast cancer is rare. Individuals with breast cancer meeting the criteria under the Listing of Impairments have a poor prognosis.
Breast Carcinoma (Stage IV), Metastatic Breast Carcinoma, Metastatic Breast Cancer, Ductal Carcinoma of the Breast (Stage IV), Metastatic Ductal Carcinoma, Metastatic Ductal Cancer, Lobular Carcinoma of the Breast Stage (IV), Metastatic Lobular Cancer, Metastatic Lobular Carcinoma, Recurrent Breast Cancer
DIAGNOSTIC TESTING AND CODING
The following may be used to diagnose the disease: mammogram, clinical breast exam, ultrasound, MRI, or biopsy (needle or incision).
Treatment may include surgery, chemotherapy, radiation, and hormone therapy.
If the cancer is inoperable or unresectable, treatment with radiation or radiation and chemotherapy/hormonal therapy can be employed for palliation.
The 5-year survival rate for individuals with stage IV breast cancer when appropriately treated is 20%. Prognosis is usually poor.
SUGGESTED PROGRAMMATIC ASSESSMENT*
Suggested MER for Evaluation: A pathology report and an operative report are the preferred methods for documentation.
In the absence of these reports, the adjudicator may use a physician's opinion that indicates the cancer is inoperable or unresectable based on described objective findings.
“Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings. Unresectable cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.
Suggested Listings for Evaluation:
13.10A, B, or C
Inoperable or unresectable Breast Cancer equals Listing 13.10A as its prognosis is similar to this listing. (A physician's opinion stating that the cancer is inoperable or an operative note stating that the cancer was not completely resected is required. In place of an operative note, a pathology report indicating positive margins may be substituted.)
* Adjudicators may, at their discretion, use the Medical Evidence of Record or Listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.
Last Updated: 9/30/08
Office of Disability Programs