Institute of Medicine report says there is "suggestive but limited" evidence. But, will VA act on this information? Probably not.

by Larry Scott, VA Watchdog dot Org

The Institute of Medicine (IOM) has issued their 13th report on veterans and Agent Orange.

While there have been many headlines over the past two days claiming a "link" between Agent Orange and Parkinson's Disease, plus ischemic heart disease (IHD), we need to step back and put some perspective on the report.

The entire report is here:
 http://www.nap.edu/catalog.php?record_id=12662

The part of the report that is causing all the excitement is this section:

Limited or Suggestive Evidence of an Association

Epidemiologic evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence. For example, a well-conducted study with strong findings in accord with less compelling results from studies of populations with similar exposures could constitute such evidence. There is limited or suggestive evidence of an association between exposure to the chemicals of interest and the following health outcomes:

Laryngeal cancer
Cancer of the lung, bronchus, or trachea
Prostate cancer
Multiple myeloma
AL amyloidosis
Early-onset transient peripheral neuropathy
Parkinson’s disease (category change from Update 2006)
Porphyria cutanea tarda
Hypertension
Ischemic heart disease (category change from Update 2006)
Type 2 diabetes (mellitus)
Spina bifida in offspring of exposed people

This means very little.  Many veterans will remember when hypertension was added to this list.  The Texas Veterans' Commission mistakenly assumed that hypertension would be made a presumptive condition for Agent Orange exposure and started taking claims from veterans.  Big error!  Then VA Secretary James Peake said NO to a presumptive for hypertension.

My best-guess on this is:

1.  Parkinson's Disease will be approved as a presumptive because so few are affected and it won't cost the VA a lot of money.  Then the Obama / Shinseki machine can make a big deal about how they are taking care of veterans, even if it is only a few of them.

2.  IHD will not be approved as a presumptive because every Vietnam veteran who has ever had a chest pain will file a claim.  This could cost the VA billions.  And, quite frankly, like hypertension, the medical evidence just isn't there to support a presumptive condition.  Here is a quick look at IHD information from Wikipedia ...

Ischaemic or ischemic heart disease (IHD), or myocardial ischaemia, is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries). Its risk increases with age, smoking, hypercholesterolaemia (high cholesterol levels), diabetes, hypertension (high blood pressure) and is more common in men and those who have close relatives with ischaemic heart disease.

Symptoms of stable ischaemic heart disease include angina (characteristic chest pain on exertion) and decreased exercise tolerance. Unstable IHD presents itself as chest pain or other symptoms at rest, or rapidly worsening angina. Diagnosis of IHD is with an electrocardiogram, blood tests (cardiac markers), cardiac stress testing or a coronary angiogram. Depending on the symptoms and risk, treatment may be with medication, percutaneous coronary intervention (angioplasty) or coronary artery bypass surgery (CABG).

It is the most common cause of death in most Western countries, and a major cause of hospital admissions. There is limited evidence for population screening, but prevention (with a healthy diet and sometimes medication for diabetes, cholesterol and high blood pressure) is used both to prevent IHD and to decrease the risk of complications.

Following is a news article on the IOM report:

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Agent Orange Linked to Parkinson's, Heart Disease

Study finds possible increased risk of both conditions among Vietnam vets

Study finds "suggestive but limited evidence" of increased risk of both conditions among Vietnam vets.

By Amanda Gardner, HealthDay Reporter

(HealthDay News) -- Exposure to Agent Orange and other herbicides that were sprayed far and wide by the U.S. military during the Vietnam War might put veterans at increased risk for heart disease and Parkinson's.

An Institute of Medicine report released Friday finds "suggestive but limited" evidence of an elevated risk for these two conditions among soldiers who served in that conflict.

Agent Orange is made up of compounds known to be contaminated with a type of dioxin -- tetrachlorodibenzo-para-dioxin (TCDD) -- during manufacture. The chemical, named for the color of the barrel it was stored in, was one of the "broad-leaf defoliants" used in Vietnam to destroy vegetation to make enemy activity easier to spot.

Between 1962 and 1970, more than 20 million gallons of herbicides were sprayed in the jungles of Vietnam so that American forces could fight more effectively; Agent Orange was the herbicide used most often to accomplish this goal. The International Agency for Research on Cancer reclassified TCDD a group 1 carcinogen in 1997, a classification that also includes arsenic, asbestos and gamma radiation, according to background information in the study.

The IOM's report is the seventh update in a series requested by the U.S. Department of Veterans Affairs and mandated by Congress.

Parkinson's and heart disease were in the category of "inadequate or insufficient evidence until this report," said Richard A. Fenske, chair of the committee that compiled the report and a professor in the School of Public Health at the University of Washington in Seattle. "Those two have been moved to the limited or suggestive evidence of an association, and those are the only two that have been changed."

The "upgrade" of Parkinson's did not surprise Deborah Cory-Slechta, a professor of environmental medicine at the University of Rochester Medical Center in New York, but she said the outcome could have gone either way.

"It seems like it was on the fence a little bit," she said. "There are people who would argue the evidence is not very compelling at the current time."

Relationships between herbicides and Parkinson's disease have been noted in the epidemiologic literature, she said. "How close these are to herbicides of interest in this case is certainly more controversial," she added.

"Herbicides, yes. These specific cast of characters, I waffle about how strong that evidence is at this time," she said. "The committee recognized this, and I agree with their statement that this should be followed in some of the cohorts."

Recent studies have also suggested links between Agent Orange and aggressive forms of prostate cancer and high blood pressure.

Other committee findings, some confirming previously reported information, follow:

* It found "sufficient" evidence of a link between herbicide exposure and soft-tissue sarcoma, non-Hodgkin lymphoma, chronic lymphocytic leukemia (CLL) and other chronic B-cell leukemias, Hodgkin's disease and chloracne, a skin condition. The committee also clarified that hairy cell leukemia belonged in the same category as CLL and lymphomas.

* In addition to Parkinson's and heart disease, there was "limited or suggestive evidence" of an association between the herbicides and laryngeal cancer as well as cancers of the lung, bronchus, trachea and prostate, multiple myeloma, AL amyloidosis (a blood disorder) and type 2 diabetes.

* There was also "limited or suggestive evidence" between a parent's exposure to herbicides and spina bifida in offspring, along with a call for more studies on health issues in the children of veterans.

* There was "inadequate or insufficient evidence" to correlate the herbicides with many other cancers, including esophageal, stomach, colorectal and pancreatic; with miscarriages, stillbirths or low birth weight in the offspring of exposed veterans or with neurodegenerative diseases other than Parkinson's. However, the committee found "limited or suggestive evidence of no association" in miscarriages after a father's exposure to TCDD.

The committee noted there had been little or no follow-up on previous, similar recommendations.

More connections between exposure to these herbicides and different health problems are likely to come to light in the future, experts predicted.

"As we grow older, we become more fragile, and problems may not show up until we get more fragile," said Keith A. Young, vice chair for research at the Texas A&M Health Science Center College of Medicine, in the department of psychiatry and behavioral science. He is also neuroimaging and genetics core leader at the VA Center of Excellence for Research on Returning War Veterans at the Central Texas Veterans Health Care System.

"Differences tend to accumulate, and diagnoses get more sure and valid," he said. "As time goes on, the underlying pathology starts to break through, and we're able to see it more clearly. The chemical exposure did some damage that starts to be expressed as our bodies become more fragile."

The evidence "certainly point to the value of collecting lots of data on lots of different conditions to understand the effects of the environment on our bodies," Young said.

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TOPICS: veterans, veterans' benefits, VA, Department of Veterans' Affairs, Institute of Medicine, IOM, Agent Orange, Parkinson's Disease, ischemic heart disease