Head and Neck Cancer

Residual Function Capacity Assessment for Head and Neck Cancer

What Is RFC?

When your head and neck cancer is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process.RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.

Assessing Impairment Caused by Head and Neck Cancer

There are several important RFC issues to consider in a head and neck cancer claim when the listing is not satisfied. Attention to the following issues will sometimes lead to a medical-vocational allowance that otherwise would be over-looked.

1. Those claimants who are smokers should have pulmonary evaluation with spirometry, because there is a high probability of chronic obstructive pulmonary disease (COPD). See How to Get Disability Benefits for Chronic Persistent Lung Infections by Meeting a Listing. Do not assume that the treating cancer specialist will necessarily diagnose COPD when it is present; make sure that there is enough evidence to make an independent determination in that regard—at least a plain chest x-ray and questions about shortness of breath. Note that a claimant can have significant COPD without having shortness of breath, if they lead a very sedentary lifestyle. If their chest x-ray is shows COPD, pulmonary function testing would still be indicated—particularly if a medium or light work RFC would result in a medical-vocational allowance.
2. Surgery and/or radiation involving the tongue and mouth, or the larynx, will impair speech. The most recent treatment involves improved use of chemotherapy and radiation to preserve the larynx, which can be accomplished 75-80% of the time. At a median of 5 years, 28% of cases have no laryngeal and esophageal dysfunction, 57% have voice disability of any degree, 28% moderate, and 15% severe residual impairment. Forty percent report no eating or swallowing problems, while 27% use nutritional supplements and only 8% dependent on a feeding tube.
3. The spinal accessory nerve is sometimes cut during radical neck dissection. A careful surgeon will try to preserve the nerve, but this is not always possible if it is involved with cancer. The spinal accessory nerve innervates the associated right or left trapezius muscles in the upper back. This muscle helps elevate the shoulder and arm. If the spinal accessory nerve is cut during radical neck surgery, the effect of the weak trapezium muscle should be taken into account on an RFC when a listing is not met. The deltoid muscles will still allow some elevation of the arm, but with loss of the trapezius function, abduction of the arm in the horizontal position is rarely possible beyond about 60-70 degrees. Therefore, if the spinal accessory nerve has been cut, a claimant should not be returned to jobs requiring any overhead work on the affected side. Furthermore, their overall lifting capacity is at least moderately restricted, i.e., the RFC should not exceed medium work.

Onset

Onset is frequently an issue in cancer cases. Generally, it is not unreasonable to assume a medical onset for disability purposes of 6 months prior to the first objective evidence of allowance-severity cancer. Note that the first objective evidence might be some type of imaging like a CT or MRI scan, which is soon thereafter biopsy-confirmed. However, the 6-month guideline should not even require symptoms since cancers can be present for years before symptoms begin. If symptoms are present, additional flexibility in adjudication is indicated. For example, a Title II claimant who stopped work from intractable back pain 7months before application for benefits, and whose back pain was caused by the subsequent diagnosis of metastatic cancer could receive a medical onset at the time of work cessation.

Chemotherapy and Other Treatments

While cancer treatments (including the side effects of medications) can be quite distressing to patients, therapy of any kind usually does not last 12 months as one continuous and medically severe duration. In the great majority of cases, the treating physicians cannot provide planned chemotherapy protocols expected to last a year. The fact of the matter is that patients cannot tolerate a year of steady chemotherapy toxicity. Trying to establish disability on the basis of drug toxicity side-effects is usually just a waste of time regarding acute side-effects, since there will be a failure of duration in that regard. Chronic toxicity, such as effects on the nervous system, is another matter (see “mental function” below). If duration is satisfied then anemia is always an important consideration in cancer cases where treatment with chemotherapy is involved.

The adjudicator should always be cognizant of the pulmonary and cardiac toxicity of some anti-cancer drugs that can remain after treatment stops, and the potential of intestinal (bowel) damage from surgery and/or therapeutic radiation when abdominal cancer is involved.

Mental Function

Decline in cognitive capacity is a serious consideration for patients receiving treatment for cancer, particularly if they have been treated for two or more years. Chemotherapeutic agents can be neurologically toxic, and radiation delivered to the brain can have deleterious effects on brain and mental function. Cancer in the brain does not necessarily have to be present; prophylactic cranial irradiation (PCI) may be part of a treatment regimen, as with certain cases of small cell lung cancer. The treating physician should always be asked if (1) the claimant has had any evidence of cognitive decline during the course of treatment, and (2) if there has been any whole brain radiation given. If either (1) or (2) is true, the SSA should obtain formal mental status and perhaps neuropsychological testing. This is an area of potential impairment which the SSA adjudicator is very likely to overlook.

Continue to Getting Your Doctor’s Medical Opinion About What You Can Still Do.

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