Story ID: 
AINsight: Cancer and Flying, Part 2
By: Robert Sancetta
Caption: FAA program allows many AMEs to issue medicals on the spot for pilots with stabilized cancers
Word Count: 1356
In my last blog, I introduced a discussion of cancer and its many implications for pilots. As mentioned, while any diagnosis of cancer is going to bring about fear and trepidation, many cancers are now quite survivable.
Unfortunately, there are also some cancers that will lead to permanent disability and even death. I do want to recognize this troublesome possibility and express condolences to those whose cancers have proven to be grave transitions for themselves and their families.
Of the pilots with a cancer diagnosis, many receive a favorable prognosis—that their cancer is likely going to be survivable—and the reassurance that it should not cause permanent disability. That news comes with quite a sense of relief.
In those cases, inevitably, a pilot quickly transitions their thoughts back to aviation. The understandable fear is that their aviation days are over. And, even if medical certification might be possible once the cancer has been treated, is the process going to morph into a proverbial “goat rope” of battles with the FAA?
In the past, virtually every cancer (except for some of the less severe variants of skin cancer) was followed by the FAA under a special issuance authorization (SIA) with complicated, ongoing, and extensive documentation. Cancers that have metastasized (spread) and are more complicated in their treatment and prognosis will, of course, be followed carefully by the FAA.
However, the light at the end of the tunnel here is that many cancers can currently be followed by the AME under the Conditions the AME Can Issue (CACI) program. An extensive and growing number of medical conditions that previously required an SIA can now be followed under CACI.
The CACI Program can be used by pilots and AMEs for asthma, kidney stones, some thyroid disorders, glaucoma, pre-diabetes, and, more recently, the management of weight loss medications. There are other conditions that can be followed under CACI, but as is apparent, the FAA is permitting a wide variety of disorders to be managed with this excellent program.
As a refresher, under CACI, the AME must still acquire and review the appropriate documentation for the medical condition under consideration. The aspect that simplifies the issuance of a medical certificate to the pilot is that the AME does not have to send the data to the FAA in advance, thus necessitating an extended waiting period for approval.
Under CACI, with the appropriate documentation, the AME issues the medical certificate to the pilot at the time of their exam and simply documents to the FAA that the appropriate data has been reviewed and is favorable. The FAA could always send a letter requesting to have the documentation sent to the Aerospace Medicine Certification Division (AMCD), but typically, under CACI, it is rare that the FAA feels it necessary to do this.
So long as the pilot is stable and meets the certification requirements listed for the specific CACI, the following cancers can be followed without requiring an SIA from the FAA: bladder, breast, certain leukemias and lymphomas, colon and colorectal, prostate, renal (kidney), and testicular. That is an impressive initial grouping, and it covers a significant number of cancers presented to the FAA.
I currently have pilots in my practice with many CACI conditions, both cancer and general medical.
Typically, the CACI certification requirements for individual cancers expect that the cancer has not metastasized to distant organs; is in remission; that ongoing treatments (surgery and/or other adjunctive care such as chemotherapy) are completed; that the pilot feels fit to fly; no disqualifying medications are being used; and that the “stage” of the cancer is low (staging is complicated, but basically it is a pathological analysis of the cancer to determine its size, location, and aggressiveness/risk to metastasize).
While a pilot will generally not feel well enough to fly when post-operative or receiving some of the harsher chemotherapeutic agents or radiation often needed early in treatment, certain maintenance medications are routinely permitted once stable. These include some of the medications for hormonal maintenance.
For example, in breast cancer, the use of tamoxifen (which functions as an anti-estrogen in hormone receptor-positive cancer) is permitted. Tamoxifen is used to reduce recurrence and invasiveness risk after treatment of the initial tumor.
The CACI worksheet defines for the pilot, AME, and the treating physician(s) precisely the type of documentation that will be required. This has streamlined and better defined the process for FAA purposes.
I see newly diagnosed cases of prostate cancer annually in my practice. As with the less-aggressive cases of breast cancer, the CACI program has greatly improved the process of returning a pilot to work after being treated for prostate cancer.
With cancers of the blood, such as leukemia (that does not have definable tumors that can be removed), the requirements are otherwise similar to the other CACI cancers. As long as the pilot has been treated, is stable, is at a low stage, there is no residual active disease, and the applicable blood testing parameters are favorable, with the appropriate documentation, the AME issues the medical certificate to the pilot at the time of their exam.
For cancers that can be followed under CACI, gone are the days of long waits and uncertainty regarding the outcome of the FAA review of the condition. Once stable, the AME can issue both the initial and subsequent medical certificates.
For CACI conditions, once the AME has documented the situation (through the online platform that AMEs use to transmit examination data to the FAA), usually the FAA will then send an eligibility letter that basically acknowledges that the condition is being followed under CACI. While pilots typically loathe getting letters from the FAA, this type of eligibility letter is a good thing—it affirms that the FAA is comfortable following the condition under CACI, and that, in essence, the pilot retains their FAA medical certification approval status.
Please remember, however, that at any point, if the FAA is not completely comfortable with the CACI information it is receiving in the AME transmission, it may request that the full documentation package be forwarded to the AMCD. Once the documentation is formally reviewed, the FAA will decide whether the condition can continue to be followed under CACI or whether a formal special issuance authorization is required.
A formal denial is unlikely, but in rare occasions, the FAA may determine that an AME issued the medical certificate in error.
If it has been more than five years since treatment, many of the CACI cancers can be dropped from any further follow-up documentation requirements.
When a pilot receives a concerning cancer diagnosis, sometimes their first reaction is to call the AME. I recommend that pilots take a bit of time to absorb the news, consider the ramifications with their treating medical providers, and when ready (emotionally and physically), contact the AME.
With a bit of historical information about the medical condition, the AME can then guide the pilot and their treating providers regarding the protocols that will be involved in the medical certification process.
It is always fabulous news for everyone when a pilot is going to survive a cancer diagnosis and lead a long and productive life after treatment. AMEs and the FAA are both very motivated to help pilots return to active flight status whenever possible. As always, treatment and follow-up will require some time and patience. However, once on the right track medically, pilots will often be able to return to the cockpit after surviving cancer.
Placing a number of common cancers in the CACI program is both a measure of confidence that the FAA places in AMEs and testimony to a more humanitarian direction in aviation medicine. Pilots can now feel optimistic, once a cancer is under good control, that FAA medical certification is attainable and that the process is reasonable.