Code 7529: Benign tumors affecting the genitourinary system are rated based on how they affect the systems around them. For example, if the condition interferes with renal functioning, then it would be rated under the renal rating system.
Code 7528: Malignant cancer is rated 100% while it is active. This 100% rating will continue for the first 6 months after the last treatment. The condition will then be reevaluated. If it is no longer active, then it is rated on any lasting symptoms like a benign condition.
| Symptoms | Rate Prostate Cancer As: |
|---|---|
| Post prostatectomy + PSA +0.4 | ACTIVE |
| Symptoms post-radiation +PSA that nadired at some lowest value and then increased to at least 3 rises | ACTIVE (suggests there is a disease at the cellular level present) |
| Any metastatic disease even if PSA is undetectable | ACTIVE |
| Type of Treatment | Potential Side Effects | Rating Considerations |
|---|---|---|
| watchful waiting |
◦ also called
◦ conservative management
◦ observation, or
◦ surveillance.
◦ No immediate specific therapy is being used, but cancer is active. | ◦ none, except for the continued presence and potential metastasis of cancer
◦ often used when life expectancy is short due to age or other illness since prostate cancer is slow- growing. | ◦ Review to confirm the continuation of active cancer previously confirmed by biopsy.
◦ Evaluate at 100 percent, despite the lack of treatment and possible lack of symptoms. |
| radical prostatectomy surgery which is characterized by ◦ removal of prostate gland and seminal vesicles ◦ most common treatment for localized cancer ◦ can be curative, and ◦ nerve-sparing procedure can be performed to improve chances that the patient will retain normal erectile function. | ◦ impotence, and/or ◦ incontinence. | ◦ In all cases of radical prostatectomy, award SMC (k) for LOU of a creative organ. ◦ Consider SC for ED on a facts-found basis. | | Cryotherapy, also known as cryosurgery or cryoablation, is a procedure by which the prostate and nearby tissues are frozen with liquid nitrogen via probes in the perineum. | ◦ impotence ◦ incontinence ◦ urethral scarring, and ◦ rectourethral fistula (rare). | Consider SMC (k) on a facts-found basis. | | Radiation ◦ can be curative if cancer is confined to the prostate and surrounding tissues and PSA is 15 nanograms (ng)/ml or less ◦ is also used as palliative therapy to relieve symptoms of advanced cancer, such as bone pain due to metastasis ◦ can be ◦ internal radiation therapy, or brachytherapy, in which radioactive seeds are implanted in the prostate. ◦ high dose radiation (HDR) seeds are implanted for less than a day and then removed. Radiation is present only while seeds are in place. ◦ low dose radiation (LDR) seeds are permanently implanted and give off radiation for weeks to months, depending on the radioisotope used. ◦ external radiation therapy, in which radiation is delivered by high-energy eternal radiation for six to eight weeks. | ◦ after external beam radiation ◦ impotence, and/or ◦ incontinence ◦ after brachytherapy ◦ impotence ◦ incontinence ◦ bowel problems, and/or ◦ urethral complications. | ▪ After internal HDR ▪ the radiation continues only for hours or days, so a six-month assignment of temporary 100-percent under 38 CFR 4.115b, DC 7528 is appropriate, and ▪ consider SMC (k) for impotence on a facts-found basis. ▪ After internal LDR ▪ the effective radiation should be gone by one year ▪ assign a 100-percent evaluation for one year, and ▪ schedule a review exam six months following the cessation of the one-year treatment period. Note: If radiation is used only as palliative therapy in advanced cancer, the 100-percent evaluation will continue because the cancer will remain active. Therefore ◦ review for metastatic disease, and ◦ consider permanency. | | Hormone therapy is primarily for palliation of prostate cancer which is not confined to the prostate for the purpose of testosterone deprivation. Types of hormone therapy include ◦ orchiectomy, the removal of testes to prevent testosterone production ◦ luteinizing hormone releasing hormone agonists (LHRH analogs), which can lower the testosterone as effectively as orchiectomy such as ◦ Lupron (leuprolide) ◦ Zoladex (goserelin), and ◦ busrelin ◦ estrogens or estrogen-like drugs, which lower the level of testosterone ◦ second-line hormonal drugs, which are used when first-line hormone therapy fails ◦ anti-androgens, which block the ability of the body to use androgens, such as ◦ Eulexin (flutamide) ◦ Casodex (bicalutamide), and ◦ Nilandron (nilutamide), and ◦ combined hormone therapy, which is an anti-androgen combined with orchiectomy or an LHRH agonist (analog). | ◦ after any hormone therapy ◦ hot flashes ◦ osteoporosis ◦ loss of muscle mass ◦ after orchiectomy ◦ impotence ◦ sterility ◦ loss of sex drive ◦ after anti-androgen therapy ◦ gastrointestinal upset ◦ breast tenderness ◦ gynecomastia ◦ decreased libido ◦ impotence ◦ hot flashes ◦ after LHRH analogs ◦ impotence ◦ hot flashes, and ◦ gynecomastia. | ◦ Orchiectomy results in anatomical loss of a creative organ; therefore ◦ evaluate under 38 CFR 4.115b, DC 7524, and ◦ award SMC. ◦ Hormone therapy may continue for many years; therefore ◦ review treatment records for expected duration of treatment, and ◦ consider permanence. | | chemotherapy | Depending on the type of chemotherapy used, there are multiple possible side effects. | Chemotherapy is used for palliation as current agents will not eradicate prostate cancer; therefore ◦ evaluate as 100 percent ◦ consider permanence ◦ review for metastatic disease, and ◦ if metastatic disease affects body systems other than the genitourinary system, award a separate evaluation for confirmed metastatic disease under the appropriate code for that body system. |
See M21-1MR, III.iv.4.I.3.h.
Bailey v. Wilkie, __ Vet. App. __, No. 19-2661 (January 6, 2021) (precedential)
Issues on Appeal:
Holdings:
Relevant Facts/Procedural History: BVA found discontinuance of the veteran’s 100-percent rating for residuals of prostate cancer to be proper and denied a rating in excess of 60 percent for the predominant residual of voiding dysfunction. It also declined to consider diarrhea and lymphedema as part of his residuals. After the decision, the RO granted service connection for lymphedema and TDIU. Mr. Bailey sought earlier effective dates for these grants, which the RO denied.
Court’s Analysis: Addressing whether DC 7528 allows separate evaluation of non-voiding and non-renal dysfunction, such as diarrhea and lymphedema, the Court looked to the language of DC 7528. The Court found the “conditional sentence” in the note to DC 7528 is “clear and unambiguous” in its limitation of post six-month residuals to the predominant voiding or renal dysfunction. Slip op. at 7. In addition to the plain language support for this limitation the Court also noted “the history and the purpose of the DC also accord with this interpretation.” Id. at 8. “[E]ntitlement to separate evaluations for non-voiding and non-renal dysfunctions related to prostate cancer cannot be considered part and parcel of a claim as to the proper evaluation level for prostate cancer residuals under DC 7528.” Id. at 9.