TN 20 (12-18)

DI 23022.125 Breast Cancer– with distant metastases or recurrent

COMPASSIONATE ALLOWANCE INFORMATION

BREAST CANCER

ALTERNATE NAMES

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

DESCRIPTION

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 listings have a poor prognosis.

DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM CODING

Diagnostic testing: The diagnosis of Breast Cancer is made by clinical breast examination and imaging tests, such as mammogram, ultrasound, and MRI. A needle or incisional biopsy confirms the diagnosis.

Physical findings: Individuals with listing level severity of Breast Cancer may present with:

  • A breast lump or changes in breast size or shape;

  • Skin dimpling or skin changes (e.g. Thickening, swelling or redness);

  • Nipple inversion or other nipple abnormalities (e.g. ulceration, retraction, or spontaneous bloody discharge);

  • Axillary lump or contour changes;

  • Dilated veins; or

  • Ulceration.

Signs of metastatic spread may include:

  • Breathing difficulties;

  • Bone pain;

  • Hypercalcemia;

  • Abdominal distention;

  • Jaundice;

  • Localizing neurologic signs;

  • Altered cognitive function or headache.

ICD-9: 174.9

PROGRESSION

The 5-year survival rate for breast cancers that have spread to other parts of the body tend to have a poor prognosis. The 5-year survival rate for individuals with stage IV breast cancer when appropriately treated is about 20%.

TREATMENT

Treatment may include surgery, chemotherapy, radiation, and hormone therapy.

SUGGESTED PROGRAMMATIC ASSESSMENT*
Suggested MER for Evaluation:
  • Clinical history and examination that describes the diagnostic features of the impairment.

  • Summaries of hospitalization and medical reports if we cannot get a pathology report or operative note. These summaries should provide us with details of the findings at surgery and, whenever appropriate, the pathological findings.

  • In place of an operative note, a pathology report indicating positive margins may be substituted.)

Suggested Listings for Evaluation:
DETERMINATION

LISTING

REMARKS
Meets 13.10 A, B, or C
Equals
* Adjudicators may, at their discretion, use the Medical Evidence of Record or the listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423022125
DI 23022.125 - Breast Cancer– with distant metastases or recurrent - 12/13/2018
Batch run: 12/13/2018
Rev:12/13/2018