Statement of Principles

concerning

MALIGNANT NEOPLASM OF THE STOMACH
(Reasonable Hypothesis)

(No. 74 of 2023)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated                                           23 June 2023.

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning malignant neoplasm of the stomach (Reasonable Hypothesis) (No. 74 of 2023).

2               Commencement

              This instrument commences on 25 July 2023.

3               Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning malignant neoplasm of the stomach No. 58 of 2014 (Federal Register of Legislation No. F2014L00939) made under subsections 196B(2) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about malignant neoplasm of the stomach and death from malignant neoplasm of the stomach.

Meaning of malignant neoplasm of the stomach

(2)          For the purposes of this Statement of Principles, malignant neoplasm of the stomach:

(a)          means a primary malignant neoplasm arising from the epithelial cells of the stomach; and

(b)          excludes:

(i)            stomach neuroendocrine tumours;

(ii)         gastroblastoma;

(iii)       haematolymphoid tumours including non-Hodgkin lymphoma, MALT lymphoma and Hodgkin lymphoma;

(iv)        malignant melanoma; and

(v)          mesenchymal tumours including soft tissue sarcoma.

Note: The stomach extends from the lower border of the oesophageal sphincter, up to and including the pyloric sphincter.

(3)          While malignant neoplasm of the stomach attracts ICD‑10‑AM code C16, in applying this Statement of Principles the meaning of malignant neoplasm of the stomach is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from malignant neoplasm of the stomach

(5)          For the purposes of this Statement of Principles, malignant neoplasm of the stomach, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's malignant neoplasm of the stomach.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that malignant neoplasm of the stomach and death from malignant neoplasm of the stomach can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

9               Factors that must exist

At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting malignant neoplasm of the stomach or death from malignant neoplasm of the stomach with the circumstances of a person's relevant service:

(1)          having smoked tobacco products:

(a)          in an amount of at least 15 pack-years before the clinical onset of malignant neoplasm of the stomach; and

(b)          commencing at least 10 years before the clinical onset of malignant neoplasm of the stomach; and

if smoking has ceased before the clinical onset of malignant neoplasm of the stomach, then that onset occurred within 25 years of cessation;

Note: one pack-year is defined in the Schedule 1 – Dictionary.

(2)          having received a cumulative equivalent dose of at least 0.1 sievert of ionising radiation to the stomach at least 5 years before the clinical onset of malignant neoplasm of the stomach;

Note: cumulative equivalent dose is defined in the Schedule 1 – Dictionary.

(3)          having infection with Helicobacter pylori at least 10 years before the clinical onset of malignant neoplasm of the stomach;

(4)          having chronic atrophic gastritis, where the chronic atrophic gastritis commenced at least 2 years before the clinical onset of malignant neoplasm of the stomach;

Note: chronic atrophic gastritis is defined in the Schedule 1 – Dictionary.

(5)          having undergone a partial gastrectomy at least 5 years before the clinical onset of malignant neoplasm of the stomach;

(6)          consuming alcohol in an amount of at least 400 kilograms before the clinical onset of malignant neoplasm of the stomach;

Note: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.

(7)          inability to consume an average of at least 200 grams per day of any combination of fresh fruits and allium vegetables, for at least 5 consecutive years within the 20 years before the clinical onset of malignant neoplasm of the stomach;

Note: allium vegetables are defined in the Schedule 1 – Dictionary.

(8)          consuming an average intake of at least 20 grams per day of preserved vegetables, for at least 5 consecutive years within the 20 years before the clinical onset of malignant neoplasm of the stomach;

Note: preserved vegetables are defined in the Schedule 1 – Dictionary.

(9)          having at least daily consumption of fermented soy products for at least 5 consecutive years within the 20 years before the clinical onset of malignant neoplasm of the stomach;

Note: fermented soy products are defined in the Schedule 1 – Dictionary.

(10)      having at least weekly consumption of Chinese-style salted fish for at least 5 consecutive years within the 20 years before the clinical onset of malignant neoplasm of the stomach;

Note: Chinese-style salted fish is defined in the Schedule 1 – Dictionary.

(11)      for non-cardia stomach carcinoma only, consuming an average intake of at least 25 grams per day of processed meat product, for at least 5 consecutive years within the 20 years before the clinical onset of malignant neoplasm of the stomach;

Note: non-cardia stomach carcinoma and processed meat product are defined in the Schedule 1 – Dictionary.

(12)      for cardia stomach carcinoma only, being overweight or obese for at least the 5 years before the clinical onset of malignant neoplasm of the stomach;

Note: cardia stomach carcinoma and being overweight and being obese are defined in the Schedule 1 – Dictionary.

(13)      inhaling respirable asbestos fibres in an enclosed space, at the time material containing asbestos was being applied, removed, cut, drilled, dislodged or disturbed:

(a)          for a cumulative period of at least 1,000 hours before the clinical onset of malignant neoplasm of the stomach; and

(b)          where the first inhalation of asbestos fibres commenced at least 5 years before the clinical onset of malignant neoplasm of the stomach;

Note: Disturbance of debris or dust contaminated with asbestos fibres may result in exposure to respirable asbestos fibres.

(14)      inhaling respirable asbestos fibres in an open environment, at the time material containing asbestos was being applied, removed, cut, drilled, dislodged or disturbed:

(a)          for a cumulative period of at least 3,000 hours before the clinical onset of malignant neoplasm of the stomach; and

(b)          where the first inhalation of asbestos fibres commenced at least 5 years before the clinical onset of malignant neoplasm of the stomach;

Note: Disturbance of debris or dust contaminated with asbestos fibres may result in exposure to respirable asbestos fibres.

(15)      having infection with Epstein-Barr virus at least 10 years before the clinical onset of malignant neoplasm of the stomach;

(16)      having diabetes mellitus for at least 5 years before the clinical onset of malignant neoplasm of the stomach;

(17)      having a gastric ulcer at least 5 years before the clinical onset of malignant neoplasm of the stomach;

(18)      having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of malignant neoplasm of the stomach;

Note: specified list of autoimmune diseases is defined in the Schedule 1 – Dictionary

(19)      for non-cardia stomach carcinoma only, taking a proton pump inhibitor drug for at least a continuous period of 1 year within the 5 years before the clinical onset of malignant neoplasm of the stomach, and where the last dose of the drug was taken at least 1 year before the clinical onset of malignant neoplasm of the stomach;

Note: non-cardia stomach carcinoma is defined in the Schedule 1 – Dictionary.

(20)      inhaling respirable crystalline silica in an enclosed space, at the time material containing crystalline silica dust was being produced, excavated, drilled, cut, ground or polished, or used in construction, manufacturing, cleaning or blasting:

(a)          for a cumulative period of at least 1,500 hours before the clinical onset of malignant neoplasm of the stomach; and

(b)          where the first inhalation of respirable crystalline silica dust commenced at least 1 year before the clinical onset of malignant neoplasm of the stomach;

Note: Disturbance of debris or dust contaminated with crystalline silica may result in exposure to respirable crystalline silica.

(21)      inhaling respirable crystalline silica in an open space, at the time material containing crystalline silica dust was being produced, excavated, drilled, cut, ground or polished, or used in construction, manufacturing, cleaning or blasting:

(a)          for a cumulative period of at least 3,000 hours before the clinical onset of malignant neoplasm of the stomach; and

(b)          where the first inhalation of crystalline silica dust commenced at least 1 year before the clinical onset of malignant neoplasm of the stomach;

Note: Disturbance of debris or dust contaminated with crystalline silica may result in exposure to respirable crystalline silica.

(22)      inhaling or ingesting opium on average at least weekly for at least 10 years before the clinical onset of malignant neoplasm of the stomach;

Note: opium is defined in the Schedule 1 – Dictionary.

(23)      inability to obtain appropriate clinical management for malignant neoplasm of the stomach before the clinical worsening of malignant neoplasm of the stomach.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factor set out in subsection 9(23) applies only to material contribution to, or aggravation of, malignant neoplasm of the stomach where the person's malignant neoplasm of the stomach was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                                             allium vegetables means raw or cooked, but not preserved, bulbous plants belonging to the genus Allium and includes garlic, leek, onion, chives and shallots.

                               being overweight means having a Body Mass Index (BMI) of 25 to 29.9.

Note: BMI is also defined in the Schedule 1 - Dictionary.

                               being obese means having a Body Mass Index (BMI) of 30 or greater.

Note: BMI is also defined in the Schedule 1 - Dictionary.

                               BMI means W/H2 where:

                               (a) W is the person’s weight in kilograms; and

                               (b) H is the person’s height in metres.

                               cardia stomach carcinoma means a carcinoma that has arisen in the part of the stomach immediately adjacent to and surrounding the opening of the oesophagus (the cardia of the stomach) that is distinguished histologically by the presence of cardiac glands and the absence of parietal (acid secreting) and chief (pepsin secreting) cells.

                               Chinese-style salted fish means fish preserved by salting and is characterised by using less salt and a higher degree of fermentation during the drying process than other methods because of the relatively high outdoor temperature and moisture levels. Chinese-style salted fish is a traditional part of the diet in southern China, Hong Kong, Taiwan, Malaysia, Singapore and other areas of South-East Asia.

                               chronic atrophic gastritis means inflammation of the stomach mucosa characterised by variable gland loss and inflammatory infiltrate extending below the lamina propria with distortion and destruction of the stomach glands.

                               cumulative equivalent dose means the total dose of ionising radiation received by the particular organ or tissue from external exposure, internal exposure or both, apart from normal background radiation exposure in Australia, calculated in accordance with the methodology set out in Guide to calculation of 'cumulative equivalent dose' for the purpose of applying ionising radiation factors contained in Statements of Principles determined under Part XIA of the Veterans' Entitlements Act 1986 (Cth), Australian Radiation Protection and Nuclear Safety Agency, as in force on 2 August 2017.

Note 1:              Examples of circumstances that might lead to exposure to ionising radiation include being present during or subsequent to the testing or use of nuclear weapons, undergoing diagnostic or therapeutic medical procedures involving ionising radiation, and being a member of an aircrew, leading to increased levels of exposure to cosmic radiation.

Note 2:               For the purpose of dose reconstruction, dose is calculated as an average over the mass of a specific tissue or organ. If a tissue is exposed to multiple sources of ionising radiation, the various dose estimates for each type of radiation must be combined.

                               fermented soy products means food and food additives made from fermented soybeans, examples include naturally brewed soy sauce, tamari, pickled tofu, miso, fermented bean paste, yellow soybean paste and tempeh.

                               malignant neoplasm of the stomach—see subsection 7(2).

                               MRCA means the Military Rehabilitation and Compensation Act 2004.

                               non-cardia stomach carcinoma means a carcinoma that has arisen in the mucosa of any part of the stomach, excluding that part of the stomach immediately adjacent to and surrounding the opening of the oesophagus (the cardia of the stomach) that is distinguished histologically by the presence of cardiac glands and the absence of parietal (acid secreting) and chief (pepsin secreting) cells.

                               one pack-year means the amount of tobacco consumed in smoking 20 cigarettes per day for a period of 1 year, or an equivalent amount of tobacco products. 

Note 1: An equivalent amount of tobacco products is 7,300 grams of smoking tobacco by weight, either in cigarettes, pipe tobacco or cigars, or a combination of same. For pipe tobacco, cigars or combinations of multiple tobacco types, 1 gram of tobacco is considered to be equal to one cigarette. 

Note 2: Pack-years are calculated by dividing the number of cigarettes smoked per day by 20 and multiplying this number by the number of years the person has smoked. For example, smoking 10 cigarettes per day for 10 years is equal to 5 pack-years, and smoking 40 cigarettes per day for 10 years is equal to 20 pack-years.

                               opium means the dried or boiled juice (latex) obtained from the seedpod of the poppy plant (Papaver somniferum).

                               preserved vegetables means vegetables that have been preserved by salting, fermenting or pickling.

                               processed meat product means meat, offal or meat by-products that have been transformed through salting, curing, fermentation, smoking, or other processes to improve preservation, including ham, frankfurters, salami and bacon.

                               relevant service means:

(a)          operational service under the VEA;

(b)          peacekeeping service under the VEA;

(c)          hazardous service under the VEA;

(d)          British nuclear test defence service under the VEA;

(e)          warlike service under the MRCA; or

(f)           non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                               specified list of autoimmune diseases means:

(a)          Addison disease;

(b)          dermatitis herpetiformis;

(c)          dermatomyositis;

(d)          Graves disease;

(e)          pernicious anaemia; or

(f)           systemic lupus erythematosus.

                               terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                               VEA means the Veterans' Entitlements Act 1986.