Comment from Price, Jeffrey, National Association of Disability Examiners (NADE)

NADE is pleased to have this opportunity to comment on SSA's proposed changes in the neoplastic listings. Please review our comments in the attachment or see the comments printed below. Thank you. June 25, 2008 Commissioner of Social Security PO Box 17703 Baltimore, Maryland 21235-7703 Dear Commissioner Astrue: The National Association of Disability Examiners (NADE) welcomes this opportunity to offer comments on the Notice of Proposed Rulemaking (NPRM) for evaluating malignant neoplastic diseases. This notice of proposed rulemaking (NPRM) was published in the Federal Register on April 28, 2008 and the comment period expires on June 27, 2008. NADE is a professional association whose mission is to advance the art and science of disability evaluation. Our membership base includes members that represent a broad perspective of interests regarding the Social Security and Supplemental Security Income (SSI) disability programs. While a majority of our members are employed in state Disability Determination Service (DDS) offices, and are directly involved in processing claims for Social Security and Supplemental Security Income (SSI) disability benefits, our membership also includes personnel from Social Security’s Central, Regional, and Field Offices, attorneys, claimant advocates and physicians. We believe this diversity of membership, combined with our “hands on” experience, provides us with a unique understanding of the challenges and opportunities facing the Social Security and SSI disability programs today. NADE is pleased to acknowledge there are positive changes and clarifications included in these new listings and that the NPRM reflects advances in medical knowledge, treatment, and methods for evaluating malignant neoplastic diseases. It updates the medical criteria in the listings and provides more information about how to evaluate these diseases. The new proposals include: • Adding more criteria for metastatic breast carcinoma (proposed listing 13.10B) and metastatic melanoma (proposed listing 13.03B2) because the medical literature shows that the findings in the proposed criteria are of listing-level severity. • Adding a criterion for carcinoma of the superior sulcus (including Pancoast tumors) to the listing for lung carcinoma (proposed listing 13.14C) to recognize the debilitating effects of, and the length of time needed to recover from, treatment for these tumors. • Clarification that SSA considers a brain tumor to be malignant if it is classified as grade II or higher using the World Health Organization’s classification of tumors. • Adding a criterion for medullary carcinoma to the adult listing for carcinoma of the thyroid gland (proposed listing 13.09C). (SSA is not proposing to add a comparable listing to the childhood listings because medullary carcinoma of the thyroid gland is extremely rare in children. However, we are proposing to add guidance in the introductory text of the childhood listing directing adjudicators to use listing 13.09C in childhood claims when appropriate.) NADE concurs with the addition of medullary carcinoma to the adult listing for carcinoma of the thyroid gland but we question the reasoning behind the decision to only add guidance language to the introductory text for childhood listings rather than adding a specific listing. We acknowledge such carcinomas in children are extremely rare, but we do not believe the listings are meant to exclude cancers simply because they are rare. • Deletes current listing 13.23E1c, for ovarian cancer with ruptured capsule, tumor on the serosal surface, ascites with malignant cells, or positive peritoneal washings. Current medical literature shows improved prognoses associated with these findings such that these findings alone are no longer indicative of listing-level severity. The changes also include non-substantive editorial revisions to clarify SSA’s rules, to reflect current medical terminology, and to correct minor editorial errors. We support these changes. NADE supports all of the recommended changes with the following additional comments: • Consideration should be given to using an 18 month diary for multiple myeloma when the claimant is undergoing multimodal therapy (listing 13.07 C.) • We believe SSA should consider a 12 or 18 month listing for some claims involving locally advanced breast cancer treated with multimodal therapy. Listings13.02 E and the new 13.14 C were developed in recognition of the difficulties faced by patients during initial treatment of these malignancies and the favorable prospect of a return to work after treatment and recovery. A “mini-Listing” for some forms of breast cancer would offer several advantages. Claimants with at least Stage II disease are most commonly treated with neoadjuvant chemotherapy (which may lessen the pathologically-evident burden of disease at mastectomy), surgical excision, adjuvant chemo and/or hormonal therapy, and often radiation, especially in the case of axillary involvement. These regimens generally last 7-12 months or more after diagnosis and are associated with a myriad of known side effects. Taxane therapy is an added challenge for many claimants. Treating physicians usually offer their support for “disability” during this time, and claimants who file for this impairment typically have few other barriers to returning to work after their treatment and recovery. Also, it is known that as treatment progresses, the side effects worsen. From both a claimant-focused and an administrative perspective, a limited-Length listing for some breast cancer claims makes good sense and would represent a compassionate effort by SSA to acknowledge the severity and duration of treatment for these cancers. We appreciate this opportunity to provide comments on this NPRM and look forward to further discussion involving the vocational aspects of the Social Security disability program. Sincerely, Georgina Huskey, President