Statement of Principles concerning non-melanoma malignant neoplasm of the skin (Balance of Probabilities) (No. 79 of 2024) (Cth)

Statement of Principles concerning NON-MELANOMA MALIGNANT NEOPLASM OF THE SKIN (Balance of Probabilities) (No. 79 of 2024) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 18 October 2024.

Professor Terence Campbell AM Chairperson by and on behalf of The Repatriation Medical Authority

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 non-melanoma malignant neoplasm of the skin (Balance of Probabilities) (No. 79 of 2024). 1. Commencement This instrument commences on 19 November 2024. 1. Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 1. Repeal The Statement of Principles concerning non-melanotic malignant neoplasm of the skin (Balance of Probabilities) (No. 8 of 2016) (Federal Register of Legislation No. F2016L00241) made under subsection 196B(3) and (8) of the VEA is repealed. 1. Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies. 1. Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 1. Kind of injury, disease or death to which this Statement of Principles relates 1. This Statement of Principles is about non-melanoma malignant neoplasm of the skin and death from non-melanoma malignant neoplasm of the skin. Meaning of non-melanoma malignant neoplasm of the skin 1. For the purposes of this Statement of Principles, non-melanoma malignant neoplasm of the skin: 1. means a primary malignant neoplasm arising from the non-melanotic cells of the epidermis of the skin; and 2. includes: 1. basal cell carcinoma; 2. squamous cell carcinoma; 3. squamous cell carcinoma in situ (Bowen disease) or basal cell carcinoma in situ; and 4. non-melanoma malignant neoplasm of the external aspect of the lip, subungual skin, external auditory canal skin, and anogenital skin; and 3. excludes: 1. non-melanoma malignant neoplasm mucosa lining the oral (inner) aspects of the lips, conjunctiva, and anogential mucosa; 2. malignant melanoma of the skin; 3. keratoacanthoma; 4. Merkel cell carcinoma; 5. mammary and extramammary Paget disease; 6. Kaposi sarcoma; 7. soft tissue sarcoma; 8. carcinoid tumour; 9. non-Hodgkin lymphoma; and 10. Hodgkin lymphoma. 2. While non-melanoma malignant neoplasm of the skin attracts ICD‑10‑AM codes: C00.0, C00.1, C00.2, C00.6, C00.8, C00.9, C44, C51.0, C51.1, C51.2, C51.8, C51.9, C60.0, C60.1, C60.2, C60.8, C60.9, C63.2, D04, D07.1, D07.4 , in applying this Statement of Principles the meaning of non-melanoma malignant neoplasm of the skin is that given in subsection (2). 3. 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 non-melanoma malignant neoplasm of the skin 1. For the purposes of this Statement of Principles, non-melanoma malignant neoplasm of the skin, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's non-melanoma malignant neoplasm of the skin. Note: terminal event is defined in the Schedule 1 – Dictionary. 1. Basis for determining the factors On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that non-melanoma malignant neoplasm of the skin and death from non-melanoma malignant neoplasm of the skin can be related to relevant service rendered by veterans 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. 1. Factors that must exist At least one of the following factors must exist before it can be said that, on the balance of probabilities, non-melanoma malignant neoplasm of the skin or death from non-melanoma malignant neoplasm of the skin is connected with the circumstances of a person's relevant service: 1. having sunlight exposure to unprotected skin for a cumulative period of at least 4,500 latitude equivalent hours before clinical onset; Note: latitude equivalent hours and unprotected skin are defined in the Schedule 1 - Dictionary 1. having at least 10 sunburns at the affected site at least 5 years before clinical onset; Note: sunburn is defined in the Schedule 1 - Dictionary. 1. having ultraviolet radiation exposure from an ultraviolet-emitting tanning device (excluding sunlamps) on at least 20 occasions at the affected site before clinical onset, at least 5 years before clinical onset; 2. having PUVA therapy, where: 1. the first PUVA treatment commenced at least 5 years before clinical onset; and 2. at least 100 PUVA treatments were administered before clinical onset; Note: PUVA therapy is defined in the Schedule 1 - Dictionary. 1. having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the affected site at least 10 years before clinical onset of basal cell carcinoma; Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary. 1. undergoing a course of radiotherapy for cancer at the affected site, at least 10 years before clinical onset; 2. being infected by the same human papillomavirus type 16, 18 or 33 for at least 2 consecutive years before clinical onset of squamous cell carcinoma of the penis, vulva or perianal skin; 3. being infected with human immunodeficiency virus before clinical onset; 4. undergoing solid organ (excluding corneal transplant) or bone marrow transplantation at least 10 years before clinical onset; 5. taking one of the following medications within the 5 years before clinical onset: 1. acalabrutinib; 2. azathioprine; 3. ciclosporin; 4. elotuzumab; 5. fingolimod 6. hydroxycarbimide (hydroxyurea); 7. ibrutinib; 8. methotrexate; 9. mycophenolate; 10. ruxolitinib; 11. siponimod 12. sirolimus; 13. tacrolimus; 14. tofacitinib; 15. upadacitinib; 16. ustekinumab; 17. zanubrutinib; 18. tumour necrosis factor-α inhibitors adalimumab, certolizumab, etanercept, golimumab, or infliximab; or 19. BRAF kinase inhibitors dabrafenib, encorafenib, vemurafenib. 6. taking ripretinib within the 5 years before clinical onset of squamous cell carcinoma of the skin; 7. taking ozanimod or ponesimod within the 5 years before clinical onset of basal cell carcinoma of the skin; 8. taking voriconazole continuously for at least 3 months, at least 1 year before clinical onset of squamous cell carcinoma of the skin 9. taking a cumulative dose of at least 25 g of hydrochlorothiazide, at least 1 year before clinical onset of squamous cell carcinoma of the skin; 10. having autoimmune hepatitis at the time of clinical onset; 11. having inflammatory bowel disease at the time of clinical onset; 12. having chronic osteomyelitis with a sinus tract draining to the affected skin site at least 5 years before clinical onset of squamous cell carcinoma; Note: sinus tract is defined in the Schedule 1 - Dictionary. 1. having non-Hodgkin lymphoma before clinical onset; 2. having mature B-cell lymphoid leukaemia and small lymphocytic lymphoma before clinical onset; Note: Mature B-cell lymphoid leukaemia and small lymphocytic lymphoma is also known as chronic lymphocytic leukaemia/small cell lymphoma. 1. having phimosis for a continuous period of at least 2 years before clinical onset of squamous cell carcinoma of the glans penis or prepuce of the penis; Note: phimosis is defined in the Schedule 1 - Dictionary. 1. having a scar at the affected site at least 10 years before clinical onset; 2. having ulceration at the affected site for a cumulative period of at least 1 year, at least 10 years before clinical onset; 3. having lichen sclerosus at the affected site, at least 10 years before clinical onset of squamous cell carcinoma of the penis, vulva or perianal skin; 4. having hidradenitis suppurativa at the affected site, at least 10 years before clinical onset of squamous cell carcinoma of the skin; Note: hidradenitis suppurativa is defined in the Schedule 1 - Dictionary. 1. being exposed to arsenic as detailed below, at least 10 years before clinical onset; 1. consuming arsenic containing compounds (for example, Fowler's solution) for a cumulative period of at least 3 months; or 2. consuming drinking water with an average arsenic concentration of at least 50 micrograms per litre for a cumulative period of at least 5 years; or 3. inhaling, ingesting or having cutaneous contact with a pesticide containing arsenic, or arsenic in copper smelting operations, for a cumulative period of at least 1,000 hours; or 4. having clinical evidence of chronic arsenic toxicity. 2. having cutaneous contact at the affected site with coal-tar distillate, for a cumulative period of at least 3,000 hours, at least 10 years before clinical onset; 3. inability to obtain appropriate clinical management for non-melanoma malignant neoplasm of the skin before clinical worsening. 1. 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(27) applies only to material contribution to, or aggravation of, non-melanoma malignant neoplasm of the skin where the person's non-melanoma malignant neoplasm of the skin was suffered or contracted before or during (but did not arise out of) the person's relevant service. 2. 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(3) 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.