APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20240038
OBJECTING PARTY: worker
REPRESENTED by: WORKER REPRESENTATIVE
RESPONDENT: employer
REPRESENTED by: self-represented
HEARING: HEARING IN WRITING
HEARD by: l. diaz, appeals resolution officer
DATED: MAY 1, 2024
ISSUES
The worker objects to the following:
The Adjudicator’s December 14, 2018 decision and February 16, 2021 reconsideration which denied entitlement to bladder cancer under the claim based upon their occupational exposures, and also based upon radiation treatment they received for their accepted follicular lymphoma (Non-Hodgkin’s Lymphoma {NHL}) under the claim.
The Adjudicator’s November 26, 2021 decision which determined there were no functional limitations associated with the worker’s follicular lymphoma, and as a result, the worker was not entitled to loss of earnings (LOE) benefits under the claim.
BACKGROUND
According to the Adjudicator’s December 14, 2018 decision, entitlement in the claim was accepted for occupationally related follicular lymphoma, with a date of accident of December 5, 2007, as a result of the worker’s occupational exposures in the petrochemical industry while employed as a Process Operator for 34 years. This decision also confirmed the allowance of follicular lymphoma for health care benefits and determined there were no functional limitations associated with this condition. The worker retired in 2010.
The December 14, 2018 decision also confirmed the worker did not have entitlement to occupationally related bladder cancer on the basis the evidence did not support the worker’s occupational exposures significantly contributed to this condition. On behalf of the worker, the worker’s representative (WR) objected to this decision, contending the worker’s occupational exposures were a significant contributing factor to the development of their bladder cancer.
The WR also objected to the decision which denied ongoing entitlement to follicular lymphoma. The WR maintained a Non-Economic Loss (NEL) benefit should have been accepted for the follicular lymphoma.
In a February 16, 2021 decision, the Adjudicator determined the evidence supported a progression in the worker’s follicular lymphoma and referred the worker’s claim for a NEL assessment. On March 9, 2021, the worker was granted a 5% NEL benefit for the diagnosis of ‘hematological cancer: follicular lymphoma (non-Hodgkin’s)’. The February 16, 2021 decision also re-confirmed the denial of entitlement to bladder cancer related to the worker’s radiation treatment for follicular lymphoma following consultation with an external Occupational Medical Consultant (OMC).
The WR then requested entitlement to loss of earnings (LOE) benefits in an October 19, 2021 letter related to the worker’s accepted follicular lymphoma under the claim, from the date they retired in 2010 until the present. Further to the November 26, 2021 Adjudicator’s decision, entitlement to LOE benefits related to the worker’s follicular lymphoma was denied on the basis the clinical evidence did not support the worker was disabled as a result of their condition, except for a brief period in 2015 when the worker received radiation treatment. However, the Adjudicator noted that during this period of time in 2015, the worker was not employed and therefore did not sustain a loss of earnings.
In summary, the issues presently before the Appeals Services Division for review are as follows: (1) entitlement to bladder cancer related to the worker’s occupational exposures and/or their radiation treatment for their accepted follicular lymphoma, and, (2) entitlement to LOE benefits from 2010 onwards related to these conditions.
Although the employer is participating in the appeal, I note they have not provided submissions for consideration. The WR’s submission will be reviewed in the body of the decision below.
AUTHORITY
Workplace Safety and Insurance Act
Section 2(1)
Section 15
Section 119
Operational Policy Manual documents: Published
11-01-02 Decision Making October 12, 2004
11-01-03 Merits and Justice October 12, 2004
15-05-01 Secondary Conditions Resulting from Work-Related February 15, 2013
Disability/Impairment
18-03-02 Payment and Reviewing LOE Benefits July 15, 2011
ADDITIONAL REFERENCE
Adjudicative Support Material, Bladder Cancer, Produced by the Occupational Disease Policy, and Research Branch (ODPRB), December 2006
ANALYSIS
- Entitlement to bladder cancer
I find the worker does not have entitlement to occupationally related bladder cancer, either due to their occupational exposures and/or to their radiation treatment for their accepted follicular lymphoma. In arriving at this decision, I had regard for the arguments presented, the relevant file information, and the applicable policies and legislation. My analysis and findings are outlined below.
Occupational disease claims are adjudicated under Section 2(1) and Section 15 of the Act and by Regulations 3 and 4 of the Act. If the disease for which the worker is claiming entitlement to benefits is not listed in the Schedules and a relevant policy has not been developed, initial entitlement is determined based on the merits and justice of the individual claim.
For entitlement to be granted under Policy 11-01-03, it must be shown that it is more probable than not that the circumstances of a worker’s employment and exposure history significantly contributed to the development of the condition being claimed.
I also considered entitlement to bladder cancer under policy 15-05-01, Secondary Conditions Resulting from Work-Related Disability/Impairment, related to the worker’s radiation treatment for bladder cancer. Policy 15-05-01 indicates that workers sustaining secondary conditions that are causally linked to the work-related injury will derive benefits to compensate for the further aggravation of the work-related impairment or for new injuries.
Brief medical review and confirmation of bladder cancer diagnosis
The file information confirms that in 2016, six years after retiring, the worker had two episodes of gross hematuria, following which a cystoscopy was performed on June 2, 2016. The worker underwent a transurethral resection of the bladder tumour on June 2, 2016. A solid high grade urothelial cancer was then diagnosed. Although radical treatment was recommended, the worker instead opted to pursue alternative treatment, including a surveillance CT scan and cystoscopy.
Occupational exposures
An occupational hygiene (OH) review was conducted on August 28, 2018 for the purposes of commenting on any relevant potential occupational exposures in the petrochemical industry and a relationship to the worker’s diagnosed follicular lymphoma and bladder cancer. The following is noted in the OH report with respect to the worker’s employment history and potential occupational exposures:
Process Operator – 1976-2010 – potential exposures included: Asbestos, coke/PETCOKE (petroleum coke) or contaminants (BTEX-benzene, dioxins), diesel exhaust and by-products of thermal degradation/combustion (boiler flue gas/PAH’s); heavy oil/asphalt mists; Varsol, metals (mercury, catalytic sludge i.e. arsenic, silica, nickel, cobalt), Hydrogen sulphide, acids, water treatment/process additives (phenol based anti-foulants, oxidants (BHT), amines, and fats (anti-foaming agent)).
Bricklayer apprentice – 1974-1976 – silica, asbestos, cement, metals (slag additives: chromium, cobalt).
Process Operator – 1973-1974 - asbestos, gasoline, BTEX, acids, catalytic sludge metals (cobalt/nickel, lead, arsenic).
Millwright apprentice – 1971-1973 – Grains, bio-aerosols, organic solvents (including benzene, toluene, xylene, machine oils, lubricants, grease).
The WSIB OH report confirms the following with respect to the worker’s occupational exposures at Company Y, which would have resulted in their most significant exposures:
As a process operator, typically his main duties would have involved monitoring for leaks and process equipment malfunctions, routine maintenance, flushing chemical lines to prepare them for trades and repair work and daily quality control sampling of the process streams. Typically process operators may take on average 3 - 4 samples per shift, but as many as 7 depending on the product stream or process volumes. The Ministry of Labour (MOL) files from the 1970's indicated at least one sample per stream was needed. The lead operator typically may be stationed primarily in the control room, while an assistant or junior operator would spend about 20-30% in the control room and the majority of his time problem solving or taking samples in the plant. Exposure to fugitive emissions and valve leaks are not uncommon in refinery processes. Process operators may also be required to enter process tanks or confined spaces to perform reactor or filter maintenance, or tasks related to emergency breakdowns.
During the worker's term of employment, Company Y’s plant was a petrochemical refinery manufacturing solvents, synthetic rubber and plastic resins including: high density polyethylene, poly vinyl chloride (PVC), motor oils and gasoline performance additives, and organic solvents including Varsol, and aromatic solvents (benzene, xylene and toluene). According to MOL and past unrelated claim files (1985- 1992) the plant was divided into several production areas including Basic Chemicals (gas cracker, aromatics); Performance Products (paraffin, Naphtha and higher Olefins): and Polymers (Polyethylene, Polyvinyl Chloride).
In addition to the above, the WSIB Occupational Hygienist indicated that the worker’s greatest routine exposure to benzene may have occurred during their employment (unconfirmed) at Company X for 20 months prior to the mid 1970’s as a junior Process Operator. During this period, the worker’s likely mean benzene exposure, ranging from 1-10ppm, could not be discounted.
In conclusion, the WSIB Occupational Hygienist estimated that over the course of their employment, the worker may have been potentially exposed to a range of airborne chemicals, with routine exposure to various organic solvents (including benzene), coke dust, combustion and chlorination by products, metals and acids, and intermittent exposure to chlorinated solvents.
The following was an estimate of the worker’s occupational benzene exposure:
While employed as a process operator - Complex C - Coker unit for approximately 34 years (1976-2010), the worker's average exposure to benzene is estimated to have been:
(1976-1994) his daily average exposure to benzene was likely noteworthy, estimated to have been in the range of 1 ppm to possibly 10 ppm.
(1995-2010) his daily average exposure to benzene was likely in the low to moderate range (i.e., less than 0.01 - 0. 3 ppm), with possible higher average exposures up to1.7 ppm during maintenance activities of 1-2 months a year annual shut down maintenance.
Other employment (unconfirmed):
Company X (2 years 1973-1974): During this period, the worker's daily average benzene exposure was likely noteworthy in the range of 1- 10ppm.
Millwright (1971-1973): The worker was likely exposed intermittently to benzene, possibly for short durations at high concentrations.
The following was the estimate for the worker’s exposure to butadiene, chlorinated solvents, combustion by-products, water chlorination by-products, and heavy metals (in particular arsenic and cadmium):
1,3-Butadiene: The worker was not employed in the rubber industry, however the worker noted that he started his employment (1976-79) working in the hydro treating alkylation unit, where butadiene was a noted contaminant of the butylene’s produced. Data regarding potential worker exposure during the sampling program or leakage in this unit was not available. While the worker indicated that he was fully protected from acid exposure during his sampling and rounds, worker exposure to butadiene cannot be discounted.
Chlorinated Solvents: his exposure throughout his employment was intermittent to routine. However, his exposure to trichloroethylene or perchloroethylene would have been intermittent and in low to moderate exposure for short periods of duration in particular prior to the 1990's.
Combustion by products (including PAH's and diesel exhaust); the worker was intermittently exposed to diesel exhaust and routinely to Coke or Pet Coke. His routine exposure to PAH's including BaP., associated with PET coke production cannot be discounted. Studies have suggested refinery worker TWA 8 hr. exposure (n=17) to PET coke with a mean PAH (total) exposure of 5.83ug/m3 and mean B(A) P (benzo(A) pyrene) of 0 .38ug/m3; and with Petroleum tar distillate worker's mean Total PAH of 69ug/m3 and B(a) P mean of 0.02ug/m3.
Water Chlorination by-products: the worker's routine airborne exposure to mists and associated chlorination by products cannot be discounted.
Heavy metals (in particular arsenic, cadmium): The worker may have been intermittently exposed to trace concentrations of airborne arsenic and cadmium.
Following the above OH report, the worker’s file was reviewed by an external OMC, Dr. Somerville, on October 15, 2018, with respect to both the worker’s follicular lymphoma and their bladder cancer. As entitlement to follicular lymphoma was accepted based largely upon Dr. Somerville’s opinion in this review, I will focus my review of Dr. Somerville’s opinion upon his findings and conclusion related to the worker’s bladder cancer.
Dr. Somerville provided the following relevant information with respect to bladder cancer:
Bladder cancer is the ninth most common malignancy in the world. Urothelial (transitional cell) carcinoma is the major histologic type in Canada, the United States and Western Europe, accounting for approximately 90% of bladder cancers. From 1985 to 2005, the number of bladder cancers diagnosed in the U.S. increased by over 50%. In middle-aged and elderly men, bladder cancer is the second most prevalent malignancy after prostate cancer. White males have the highest risk in the United States, with approximately twice the incidence seen in men of African descent and Hispanic men. The median age at diagnosis in men is 69 years, and in women is 71 years (1). …
The urothelium that lines the entire urinary tract is exposed to potential carcinogens as they are excreted in the urine. Cigarette smoke, exposure to various chemicals, certain drugs such as cyclophosphamide and phenacetin, and radiation exposure are the major contributing factors to the development of urothelial cancer in the West. Genetic effects may also play a role in the initiation and progression of urothelial cancers. Genetic factors may modify the risk associated with exogenous agents, either through the activation or detoxification of potential carcinogens (1).
With respect to cigarette smoking, which the scientific literature confirms is the most relevant risk factor for the development of bladder cancer, the following was noted by Dr. Somerville:
Cigarette smoking is the most important factor contributing to the overall incidence of urothelial cancer. There are over 60 known carcinogens found in cigarette smoke. In the National Institutes of Health - AARP Diet and Health Study Cohort, over 465,000 individuals were followed from 1995 to 2006 in the United States. In current smokers, there was a significant increase in the risk of bladder cancer for both men and women (multivariate adjusted hazard ratios [HRs] 3.89 and 4.65, respectively). Although there was an attenuation of risk in former smokers, the risk remained significantly elevated (HRs 2.14 and 2.52 for men and women, respectively) (2). Smoking cessation decreases the risk of bladder cancer; however, the risk does not reach background levels even after 25 years or more. The National Institutes of Health - AARP Diet and Health Study Cohort Report also noted that previous studies indicate that the population attributable risk of bladder cancer for tobacco smoking is 50% to 65% in men and 20% to 30% in women.
Exposure to second-hand smoke appears to be a risk factor for women, but the risk is less clear for men.
Dr. Somerville provided the following relevant information with respect to occupational exposures and the development of bladder cancer:
Occupational carcinogen exposures are thought to account for about 10 to 20% of bladder cancers (3). Many epidemiological studies examining the association between occupation and bladder cancer incidence have shown inconsistent results though, and significant associations have been rare. Smaller studies lack adequate statistical power. Assessing the validity of the studies has often been difficult as many studies have involved questionnaires which can be affected by recall bias or contain little or no hygiene data. Studies with good control of smoking have been few. An assessment of non-occupational risk factors has often been absent in the studies as well.
However, some occupations have been linked to increased risk of bladder cancer, including metalworkers, machinists, textile and electrical workers, painters, and manufacturing jobs involving paints and plastics (4). The results demonstrating increased risk are usually modest. For example, Zeegers and colleagues (5) found only marginal evidence for an association between occupational exposure to PAHs (polycyclic aromatic hydrocarbons), aromatic amines, paint components and bladder cancer. Men in the highest percentiles of occupational exposure to paint components, PAHs, aromatic amines, and diesel exhaust had non-significantly higher age and smoking adjusted incident rate ratios (RRs) of bladder cancer than men with no exposure. The values were 1.29 (95% confidence interval (95% Cl) 0.71 to 2.33), 1.24 (95% Cl 0.68 to 2.27), 1.32 (95% Cl 0.41 to 4.23) and 1.21 (95% Cl 0.78 to 1.88), respectively. Other studies though demonstrate a stronger association between PAH exposure and risk of bladder cancer (4, 6). Those with high exposure for a prolonged period of time had the most elevated risk, although a clear dose-response relationship was not present (6).
Occupational exposure to solvents and the risk of bladder cancer has been researched in a number of studies. Lohi and colleagues (7) did a cross-sectional cohort study in Finland using 10277 cases of bladder cancer and 9904 cases of renal cell cancer. Exposure to solvents was positively associated with the incidence of bladder cancer in women, but not in men. A multicenter population-based case-control study was conducted on urothelial cancer risk (8), with exposure to the agents under study selfassessed by the participants as well as expert-rated. The risk following exposure to aromatic amines was only slightly elevated. Among males, substantial exposures to PAH as well as to chlorinated solvents and their corresponding occupational settings were associated with elevated risks after adjustment for smoking (PAH exposure, assessed with a job-exposure matrix: OR = 1.6, 95% Cl: 1.1-2.3, exposure to chlorinated solvents, assessed with a job task-exposure matrix: OR = 1.8, 95% Cl: 1.2-2.6). The elevated risk though was seen amongst males with heavy exposure.
Dr. Somerville also correctly noted that the WSIB Occupational Disease and Policy Research Branch documents have consistently found no occupational risk factors for which there is positive evidence of an increased risk of bladder cancer. He indicated that limited evidence for low to moderate risk of developing bladder cancer in a number of occupations with high-level exposures have been noted though, such as foundry workers, painters, metal machinists, and rubber industry workers.
Dr. Somerville provided the following opinion in his conclusion with respect to whether the worker’s bladder cancer was causally related to their occupational exposures:
The IW was 62 years old when diagnosed with bladder cancer. In addition to his age, another risk factor for his bladder cancer was his prior smoking history. Cigarette smoking is the most important factor contributing to the overall incidence of urothelial cancer, and while smoking cessation decreases the risk of bladder cancer, the risk does not reach background levels even after 25 years or more. A meta-analysis that included data from 88 studies found that the relative risks of bladder cancer for all smokers, current smokers, and former smokers compared with non-smokers were 2.62 (95% Cl 2.43-2.83), 3.49 (3.13-3.88), and 2.07 (1.84-2.33), respectively (9). With respect to known occupational risk factors for urinary bladder cancer, according to the occupational hygiene review, the IW may have been intermittently exposed to trace concentrations of airborne arsenic. However, there is no mention of exposure to other known or suspected bladder carcinogens. Given the current state of the epidemiology, and the lack of information demonstrating prolonged, elevated exposure to known or suspected bladder carcinogens, I cannot conclude occupational exposures caused or significantly contributed to the IW's bladder cancer.
I also had regard for the May 2, 2019 review and opinion provided by Dr. Arnold of the Occupational Health Clinics for Ontario Workers Inc. (OHCOW) with respect to whether the worker’s radiation treatment for follicular lymphoma could have significantly contributed to their bladder cancer. Dr. Arnold briefly reviewed the worker’s occupational exposures, their relevant family history, and their past smoking history, noting the worker had ceased smoking in 1988. Dr. Arnold indicated the latency between radiation and the development of cancer is usually 5 years, and that smoking is considered the number one cause of bladder cancer. Dr. Arnold acknowledged that the studies she referenced were based on a full course of radiation treatment for cancer and that the worker only had 4 treatments of radiation.
Dr. Arnold concluded that although the worker’s latency period was not typical for bladder cancer following radiation therapy, their pathology was consistent with post-radiation bladder cancer. She indicated there was no doubt the worker’s smoking history had played a role in the development of his bladder cancer, and that the worker may not have developed bladder cancer without the added risk factor of radiation therapy for their follicular lymphoma.
In response to Dr. Arnold’s May 2, 2019 report, Dr. Somerville reviewed the worker’s file once again on January 14, 2021. Following a review of the medical documents, Dr. Somerville noted that although Dr. Arnold indicated the worker had radiation treatment to the neck and pelvis, he was unable to confirm the worker had radiation to the pelvis for treatment of his NHL. Dr. Somerville specifically noted “While the nuclear medicine consultation report of March 12, 2020 states the IW has a history of follicular lymphoma in 2007 treated with radiation therapy to the left submandibular lymph node in November 2014 and the left inguinal lymph node in 2015, there are no previous consult reports on file describing radiation treatment to the left inguinal lymph node/pelvis.” Dr. Somerville noted that the CT scan report of September 9, 2014 described a large soft tissue mass in the left neck and left supraclavicular lymph nodes, but no significant lymphadenopathy elsewhere, including the pelvis. Dr. Somerville concluded there was insufficient evidence on file that the worker underwent radiation treatment to the pelvis for their follicular lymphoma.
However, Dr. Somerville documented that even if the worker had undergone a palliative dose of radiation to the left inguinal region in 2015, Dr. Arnold’s report correctly confirmed that the majority of studies linking radiotherapy with the development of bladder cancer were with respect to radiation treatment for prostate cancer, and not follicular lymphoma.
Furthermore, he also pointed out the latency period between radiation treatment and the development of bladder cancer is stated to usually be five years, and the worker was found to have bladder cancer one year and 8 months after the worker’s radiation treatment. Lastly, similar to Dr. Arnold, Dr. Somerville pointed out that studies linking radiotherapy with the development of bladder cancer were based on a full course of radiation treatment, and that it appeared the worker only had two treatments. As a result, Dr. Somerville indicated he could not conclude the worker’s radiation treatment for follicular lymphoma was an important contributor to the development of their bladder cancer. Dr. Somerville’s opinion with respect to the worker’s occupational exposures and the development of bladder cancer remained unchanged.
I also had regard for the scientific review of 2006 by the ODPRB, documented in the Adjudicative Support Material entitled Bladder Cancer. The scientific review did not identify any occupational risks for which there was positive evidence of an increased risk for bladder cancer, however, a complete review of all occupational risk factors was not undertaken. In summary, there was limited evidence of an association for rubber industry workers, foundry workers, painters, and metal machinists. There was a positive association with increasing age (risk increased with age, starting at 50 years, with 70% of cases in men and 75% of those in women occurring after age 65), sex (bladder cancer was more common in men than women), smoking (which was the most well-established and most important risk factor), treatment-related therapy (radiotherapy), arsenic in drinking water; and Schistosoma Haematobium (infection or cystitis from the parasitic blood fluke Schistosoma haematobium). There was limited evidence of an association with chronic cystitis and other infections, dietary factors, hereditary and family history, and drinking water (chlorine and chlorination-by-products). Lastly, it was noted that most epidemiological studies did not support a link between the development of bladder cancer and the consumption of alcohol, artificial sweeteners, and tea.
In their February 2024 submission, the WR argued the worker’s occupational exposures to carcinogens over their 34-year work history, and their exposure to radiation for treatment of their follicular lymphoma, on a balance of probabilities, contributed to the development of their bladder cancer. The WR indicated the data supported the worker had been exposed to known carcinogens. The WR also submitted three recent studies for consideration.
The first study submitted by the WR is entitled “Cancer Incidence and Mortality Among Petroleum Industry Workers and Residents Living in Oil Producing Communities: A Systematic Review and Meta-Analysis”, by Onyije et al, 2021, i.e., study #1. The second study submitted was “Exposure to benzene and other hydrocarbons and risk of bladder cancer among male offshore petroleum workers”, by N. Shala et al, 2023, i.e., study #2. The last article submitted by the WR is entitled “Occupational exposure to organic solvents and risk of bladder cancer”, by Xie et al, 2024, i.e., study #3.
I carefully reviewed the above studies and noted some concerns. First, study #1 is a meta-analysis of prior epidemiological studies previously published between 1990 and 2019, the majority of which would already have been considered by Dr. Somerville in his reviews of 2019 and 2021, by Dr. Arnold, and also by the International Agency for Research on Cancer (IARC). Studies #2 and #3 acknowledged only a slightly increased risk of incident bladder cancer in exposed individuals compared to the unexposed. These studies indicated that complex and heterogeneous exposure situations, and a lack of confounder control are common limitations in many occupational bladder cancer studies. Study #2 was also limited to Norwegian offshore petroleum workers with industry-specific exposures. Furthermore, the studies only suggested an association with increased risk of bladder cancer and exposure to benzene, and that it was not possible to determine whether the effect could be ascribed to benzene only, or to other aromatic hydrocarbons. It recommended additional studies of occupational exposure to benzene and bladder cancer to determine if the association is consistent and to explore the biological plausibility.
Overall, I did not find that the studies submitted by the WR provided any significant information that would alter the opinion by Dr. Somerville in his prior reviews. Of importance, all of the above studies are also limited by important confounders such as smoking, age, etc. As a reminder, epidemiological evidence confirms smoking remains the single most important risk factor for the development of bladder cancer. Lastly, it is relevant to note that the IARC does not identify benzene as a known carcinogen for bladder cancer.
The WR also submitted that the known latency period for the development of bladder cancer (estimated between 14 and 26 years from exposure) fit within the noted time frame pertaining to the worker’s exposure timeline, with the diagnosis confirmed in 2016. However, I would also point out that the age at which the worker was diagnosed with bladder cancer is quite typical among males, i.e., over 60, particularly those with a smoking history, as was the case with this worker.
The WR argued that the high-level exposure to numerous occupational carcinogens would have significantly contributed to the worker’s bladder cancer. I note there does not appear to be any dispute with respect to the worker’s accepted occupational exposures, as detailed in the OH review. I accept the evidence supports the worker’s occupational exposures while employed as a Process Operator in the petrochemical industry were as documented in the OH review, and further accept the estimate that the worker may have been exposed to only trace concentrations of airborne arsenic. However, as noted by Dr. Somerville, the OH review does not mention exposure to other known accepted occupational carcinogens.
It is also relevant to mention that the worker had been a smoker, with the file evidence confirming they ceased smoking in 1988. Medical literature confirms even though there is an attenuation of risk in former smokers, even after 25 years after ceasing smoking the risk for bladder cancer remains significantly elevated. As documented by Dr. Somerville in his review, studies indicate that the population attributable risk of bladder cancer for tobacco smoking is 50-65% in men.
Having reviewed all file medical reports, it is important to note that neither the worker’s treating medical practitioners for their follicular lymphoma and bladder cancer, nor those physicians who submitted opinions to file, including those of Dr. Arnold and Dr. Somerville, attribute the worker’s bladder cancer to their occupational exposures.
The WR also submitted the worker’s bladder cancer is causally related to the worker’s exposures to radiation while undergoing treatment for the compensable follicular lymphoma. The WR referenced Dr. Arnold’s May 2, 2019 review to support this position.
In response to the above argument, I will point out several factors which support the worker’s bladder is likely unrelated to their radiation treatment for bladder cancer. First, as mentioned by Dr. Somerville, the contemporaneous file medical reports do not support the worker received radiation treatment to the pelvic region. It is noted the worker received radiation therapy to the left submandibular lymph note in November 2014 and to the left inguinal lymph note in 2015. There were no contemporaneous treatment notes confirming radiation treatment to the left inguinal lymph node/pelvis. Although the CT of September 2014 described a large soft tissue mass in the left neck and left supraclavicular lymph nodes, it documented there was no significant lymphadenopathy elsewhere. As a result, based upon the evidence submitted, I cannot determine the worker received radiation treatment directed to the pelvic region.
Furthermore, although Dr. Arnold indicated in their report the worker had received four courses of radiation treatment, the oncology report of February 2, 2015 confirms the worker received two doses of palliative radiation treatment with good response for their follicular lymphoma. As was noted by Dr. Somerville, the studies linking radiotherapy with the development of bladder cancer were based on a full course of radiation treatment, which can often be up to 10 treatment sessions. I therefore accept the current medical evidence confirms the worker only received two treatments for their follicular lymphoma, which would be significantly less than a full course of treatment.
In addition to the above, as was mentioned by Dr. Somerville and Dr. Arnold, the majority of studies linking radiotherapy with the development of bladder cancer were with respect to radiation treatment for prostate cancer. Medical literature confirms that treatment for prostate cancer is specifically targeted at the pelvic region and typically involves more radiotherapy treatment compared to follicular lymphoma.
Lastly, scientific studies confirm the latency period between radiation treatment and the development of bladder cancer is usually 5 years. The worker was diagnosed with bladder cancer after only 1 year and 8 months of their radiation treatment.
In light of the above factors, I therefore prefer the opinion of Dr. Somerville to that of Dr. Arnold, that the evidence does not support the worker’s bladder cancer was related to treatment for their follicular lymphoma. As a result, further to policy 15-05-01, Secondary Conditions Resulting from Work-Related Disability/Impairment, I therefore cannot conclude that the worker’s bladder cancer has been shown to be causally related to the worker’s radiation treatment for follicular lymphoma.
In summary, as was noted earlier, for entitlement to be granted under Policy 11-01-03, it must be shown that it is more probable than not that the circumstances of a worker’s employment and exposure history significantly contributed to the development of the condition being claimed.
In summary, other than potential exposure to trace amounts of arsenic, I accept the evidence supports there was no confirmed exposure to other known or suspected bladder carcinogens. Having regard for the relevant epidemiological evidence, the expert medical opinions provided, and the arguments presented, and for the reasons outlined above, I do not find the evidence supports that either the worker’s occupational exposures or the worker’s radiation treatment for follicular lymphoma significantly contributed to the development of their bladder cancer. As a result, I conclude the worker does not have entitlement to bladder cancer under the claim.
- Entitlement to LOE benefits from 2010 to the present
I find the worker is not entitled to LOE benefits from 2010 to the present. In arriving at this decision, I had regard for the relevant file information, the arguments presented, and the applicable Policy. My analysis and findings are outlined below.
The WR submitted the worker opted to retire in 2010 in order to remove themselves from the environment that was a contributory culprit in making them sick. With the diagnosis of bladder cancer, the medical evidence supports the worker began experiencing limitations on their functioning that would have prevented the worker from sustaining work or remaining at work. As a result, the WR submitted that lost time beyond 2010 is causally related to the compensable cancer diagnoses and the effects of these conditions and required treatment/medications.
Policy 18-03-02 specifies that a worker who has a loss of earnings as a result of a work-related injury is entitled to payment of LOE benefits beginning when the loss of earnings begins, and that it continues until the earliest of: the day on which the worker’s LOE ceases; the day on which the worker reaches 65 years of age, if they were less than 63 years of age on the date of the injury; two years after the date of injury, if the worker was 63 years of age or older on the date of injury; or, the day on which the worker is no longer impaired as a result of the injury.
In this particular case, there does not appear to be any dispute that the file medical information confirms the worker remained asymptomatic with respect to their follicular lymphoma, apart from the two radiotherapy treatments received in 2015. The file medical reports do not confirm any functional limitations in connection with the worker’s follicular lymphoma, which does not appear to be undisputed by the WR. As a result, I do not find the evidence supports the worker was impaired from performing their regular job duties in relation to the worker’s follicular lymphoma.
Furthermore, after 34 years of service with the accident employer, I note the file evidence confirms the worker opted to retire in 2010. I note the worker retired at a period in time when they had no functional limitations.
Having regard for the above, I therefore conclude the worker is not entitled to LOE benefits in relation to their accepted follicular lymphoma under the claim.
Although I accept the WR’s submission that the worker’s diagnosed bladder cancer could have prevented the worker from sustaining work or remaining at work, unfortunately, as indicated earlier, the worker’s bladder cancer has not been found to be occupationally related. As a result, I therefore conclude the worker is therefore not entitled to LOE benefits in relation to their inability to work related to their bladder cancer.
CONCLUSION
I conclude the following:
The worker does not have entitlement to bladder cancer related to their occupational exposures and/or related to their radiation treatment for their follicular lymphoma.
The worker is not entitled to LOE benefits under the claim.
DATED May 1, 2024
L. Diaz
Appeals Resolution Officer
Appeals Services Division