Lymphoid malignancy

Guidance for medical examiners when assessing a patient for either a general topic or condition -  Lymphoid malignancy.

Definition

This guidance should be used for applicants with:

  • Malignancy of the haemopoetic and immune system.

Aeromedical implications 

Effect of aviation on condition

  • Clinical effect of relative hypoxia may be amplified in the context of anaemia of lymphoid malignancy

Effect of condition on aviation

  • Overt incapacitation from relapses that may present with retinal bleeds, neuropathy, seizure or abdominal pain
  • Subtle incapacitation from fatigue, fever, sweats, headache, nausea, vomiting, diarrhoea, or comorbid depression
  • Distraction due to treatment and symptoms

Effect of treatment on aviation

  • Radiotherapy to the chest may cause cardiac complications of aeromedical significance
  • Anthracycline therapy may cause cardiac complications of aeromedical significance

Approach to medical certification

Based on the condition

  • Definitive and stable diagnosis
  • Staging
  • Prognosis
    • relapse free survival
    • event free survival
    • overall survival
  • International Prognostic Index (IPI).

Based on treatment

  • Treatment of primary disease completed
  • Demonstrated remission
  • Assessment of organ damage secondary to treatment

Demonstrated stability

  • Absence of symptoms
  • No continuing side effects of treatment

Risk assessment protocol - information required

New cases

  • Confirmed diagnosis
  • History
    • presentation and course of illness including dates
    • assessment for co-morbid disease eg depression
  • Clinical status (debility, pain, GI symptoms etc.)
  • Grade and stage of malignancy (please include relevant staging investigation reports, scans etc.)
  • Management
  • Treatment (types and dates of treatment)
    • surgery
    • chemotherapy (curative, adjuvant, palliative) (specify if anthracyclines)
    • radiotherapy (curative, adjuvant, palliative)
    • hormone therapy
  • Complications of treatment (note investigations or referrals to other specialists)
  • Follow-up plan
    • frequency of clinical radiological imaging
    • frequency of haematological testing
  • Ongoing treatment
    • description of specific therapy
  • Prognosis and Prognostic factors
  • Risk of possible future recurrence
    • What are the likely clinical presentations of recurrence?
    • Could this be accompanied by incapacitating symptoms?
    • Could a recurrence be detected before symptoms occur by increasing the frequency of radiological, haematological or other surveillance?
  • References to relevant medical literature.

Renewal

  • Confirmed diagnosis (any progression or change to diagnosis)
  • History
  • Clinical status
    • any evidence of recurrence
    • any evidence of late stage complications of disease or primary treatment
    • assessment for comorbid depression / pain / symptoms
  • Management (requirement for any additional treatment since initial primary treatment)
  • Complications of treatment (note investigations or referrals to other specialists)
  • Prognosis
  • Risk of possible future recurrence
    • What are the likely clinical presentations of recurrence?
    • Could this be accompanied by incapacitating symptoms?
    • Could a recurrence be detected before symptoms occur by increasing the frequency of radiological, haematological or other surveillance?
  • Follow-up plan
    • frequency of clinical radiological imaging
    • frequency of haematological testing
  • References to relevant medical literature.

Indicative outcomes

  • Primary treatment of the disease should be completed before an assessment can be made of a return to flying or controlling
  • Adverse prognostic factors will normally lead to a longer period before a return to flying and conversely positive prognostic factors will normally lead to a shorter period before a return to flying or controlling
  • A longer time period should normally elapse before returning to flying or controlling after a relapse than is required after primary treatment
  • Anthracycline therapy requires additional period of surveillance and specialist review
  • Common time frames for return to flying and controlling duties:
    • 6 weeks following completion of radiotherapy
    • 2 months following completion of chemotherapy
    • 6 months following completion of anthracycline chemotherapy in addition to satisfactory cardiac assessment
  • This does depend on the type of lymphoid malignancy and treatment given, and longer no-flying/no-controlling periods may be required. Each application is assessed on a case-by-case basis.

Favourable

  • Clinically 'well'
  • No evidence of residual malignant disease after treatment
  • No evidence of complications from treatment likely to interfere with flight safety
  • Satisfactory haematological parameters
    • Haemoglobin Male > 120g/L
    • Haemoglobin Female >115g/L
    • Platelets > 100X109 /L
    • White cell count > 3X109 /L
    • Neutrophils > 1X109 /L.

Unfavourable

  • Ongoing treatment
  • Significant cardiac disease secondary to treatment
  • Treatment resistant disease
  • Comorbid depression or systemic symptoms eg malaise, lethargy, nausea, pain

Pilot and controller information

  • Any relapse or recurrence must be notified to CASA
  • If certification is possible,  restrictions may be required
  • Audit requirements are likely

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

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