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