Story ID: 
AINsight: Cancer and Flying, Part 1
By: Robert Sancetta
Caption: Most pilots can continue flying even with a cancer diagnosis
Word Count: 1592
Receiving the diagnosis of any type of cancer will usually lead to a period of uncertainty and concern. Other than for a “simple” skin cancer, for example (and even those cancers are not always quite so simple), most cancer diagnoses cause strong emotional responses. This is completely understandable and expected.
After that ominous introduction, the good news is that most cancers are survivable. The process may be difficult and may also require lifelong monitoring after the initial treatment protocols. Yet, at other times, the treatment and follow-up may not be all that challenging or burdensome.
For a pilot, of course, the big question is always whether or not they will be able to continue flying. Usually, the answer to that question is “yes.”
I often have pilots contact me to discuss whether they should even embark on the treatment program recommended by their physician, worrying that it might impact their ability to fly. That is a reasonable question for a pilot, and it requires a tactful and compassionate discussion on my end.
I usually lead off with the disclaimer that in the case of any major medical setback (cancer or otherwise), a patient should always strongly consider the advice given to them by their treating specialists. As an AME, I am not a cancer specialist, but I can certainly advise the pilot on the protocols that will be followed to comply with the FAA medical standards and expectations.
A corny reminder that I use with pilots to emphasize the importance of following their physician’s recommendations first and foremost, and worrying about their FAA medical certificates as a distant second consideration, is this: “It is easier for me to keep you flying if you are still alive.” Bottom line: get treated properly—the FAA will expect that, and the pilot’s family will expect that.
And, once the shock of the diagnosis has subsided a bit, the pilot typically wants to be treated properly and fully. The FAA medical, while never truly taking a distant back seat in the pilot’s mind, becomes secondary to receiving proper medical care.
Regarding FAA medical certification, calling the AME should not be a pilot’s first consideration. However, once they know a bit more about the type of cancer they have been diagnosed with and what the treatment plans and prognosis are, seeking advice on protocols and timing from their AME is a good idea. That way, the AME can offer strategies to facilitate the issuance of the next medical certificate and/or an application to the FAA in a timely manner.
I will discuss more specifically many individual types of cancer and the applicable FAA medical implications in part two of this series. I will provide some general guidelines and principles in this initial discussion and clarify further in part two.
Cancers of lesser severity can often be handled by the AME relatively simply. In fact, many cancers will not even require a special issuance authorization from the FAA for the pilot to be able to obtain a medical certificate.
In the case of lesser-risk skin cancers, at times, the AME would only have to discuss the situation with the pilot and document that discussion in the AME’s internal exam notes to the FAA. The pilot is not required to provide any medical data in these situations.
This would apply, for example, to basal and squamous cell skin cancers that have been fully excised and have not recurred. The pilot’s medical certificate is issued routinely at the time of exam. Melanoma presents additional risks and complications that may or may not preclude the AME from issuing the certificate at the time of exam. (I will discuss this condition in part two.)
In general, for most cancers, documentation will be required to be presented to the AME. Even in many of these cases, a special issuance is not required. I have discussed the conditions the AME can issue (CACI) in prior blogs. Under CACI, while the AME must continue to review applicable data, the medical certificate can be issued at the time of exam for these conditions.
The AME again documents that they have reviewed all of the required data, and if it meets FAA medical expectations, the pilot is therefore “CACI qualified.” Under CACI, the AME does not need to forward the data to the FAA.
While there will be many more nuances, the CACI program may apply to specific cases of prostate, colon, breast, and several other types of cancer. Obviously, the kind of information that the FAA is looking for in these cases is that the cancer has not metastasized (spread), ongoing treatment is completed, and the pilot is stable and without significant residual deficits, et cetera.
In the examples noted above, the AME can issue the certificate at the time of exam without waiting for the initial FAA approval.
When a cancer is a bit too complicated to be followed under CACI, but the FAA is satisfied that it has been well-treated and is stable, that cancer may be approved under the special issuance program. These cancers are often those that had previously metastasized or present an elevated risk of later metastasizing to other organs, which can result in significant disability.
Some cancers may metastasize to the brain. In these cases, imaging studies such as a brain MRI may be required. We do not want the first indication of a metastasis to the brain to be a seizure during flight. Catching any looming metastasis proactively with an MRI not only enhances the safety of flight but also puts the pilot in a position to receive timely additional treatments.
Even some of the cancers I have noted that can be followed under CACI can also be at risk of metastasizing to bone or brain, for example. This is why the FAA requires the AME to be certain that the treatment was initiated early enough that such metastasis has not occurred. For any cancer that may have been followed under CACI, if the pilot later exhibits any higher-risk features, they will then be followed under a special issuance.
As a reminder, any case that requires a formal special issuance authorization necessitates the FAA to pre-review the required documentation before the granting of the initial special issuance. The pilot, therefore, will have a period of grounding while their case is reviewed. Add that to whatever amount of time it took to stabilize the cancer, and the pilot sometimes endures an extended period off from flight status.
Patience will be required both during the treatment phase and the FAA review phase. However, at least the pilot is living and breathing and hopefully still “in the game” regarding their flying aspirations.
Once approved by the FAA, at the discretion of the Aerospace Medical Certification Division (AMCD), there are two basic types of special issuance authorizations that apply. For more complicated cases, the traditional type of special issuance authorization will require that interim documentation be submitted to the AMCD in advance of the expiration date of the pilot’s medical certificate. The pilot then has to wait for a new authorization before the AME can issue the subsequent certificate. As you already know, this type of recurring waiting game is quite tedious and stressful for pilots.
In cases of cancers that do require a special issuance but are of somewhat lower risk, sometimes they are approved under the AME Assisted Special Issuance (AASI) program. While there will still be the dreaded wait for that coveted initial FAA approval, under AASI, all follow-up approvals can be done on the spot by the AME. While additional interval data will be required, as long as it is favorable, the AME can issue and then send the data for FAA review afterwards. This is a great program for pilots since all subsequent issuances no longer require the daily dance of going to the mailbox awaiting FAA letters.
I keep discussing the “applicable documentation” that is required. While I will cover this in more specifics in part two, as noted above, data relevant to individual cancers is required to demonstrate that it is well-treated and stable.
While many cancers do not permanently impact a pilot’s career or avocation, I must be clear that some either are terminal or will significantly impact the pilot’s life and future. At times, the treatment is brutal. It behooves all of us to respect that such situations are terrible for the pilot and their family, and we must provide our understanding, concern, and sympathies.
In that light, I try to be available to a pilot—even when they are fighting for their life. Regardless of the odds of ever regaining a medical certificate or how long that might take, if I can provide even a glimmer of hope, that assurance goes a long way for the pilot.
While remaining honest and reasonable (I certainly do not want to mislead or give false expectations), if I can provide any optimism for that pilot, I am happy to do so. That way, the pilot does not feel as though they are forgotten and out in the proverbial cold regarding the information they may eventually need to resume their occupation or avocation.