VA Adds Bladder Cancer as Potential Effect of Agent Orange Exposure

CUREGenitourinary Cancers Special Issue 2021

Agent Orange exposure impacted millions of U.S. military personnel during the Vietnam War. The chemical may have led to bladder cancer diagnoses later in life.

The U.S. Department of Veterans Affairs (VA) recently added three more presumptive conditions related to Agent Orange exposure —bladder cancer, hypothyroidism and Parkinsonism — which has the potential to impact many Vietnam veterans who were exposed to the tactical herbicide.

“Bladder cancer is predominantly found in males and increases with age,” a VA spokesperson told CURE®. “It is one of the top five cancers found in men. It is associated with several risk factors including smoking as well as genetic and familial causes, but has also been linked in some cases to occupational exposures.”

According to a consensus study report published in 1994, approximately 11 million gallons of Agent Orange were sprayed by the U.S. Air Force from 1962 to 1971 in Vietnam. This was primarily done to defoliate trees and plants to improve observation on the ground and to destroy enemy crops. Although it may be difficult to estimate how many people were exposed to Agent Orange, anywhere between 2.6 and 3.8 million U.S. military personnel served in Vietnam during this period.

“There have been epidemiological data in … 2014 (that) suggest there was an association between bladder cancer and Agent Orange exposure, with higher levels of exposure being associated with an approximately two-fold increase in death from bladder cancer,” Dr. Vikram M. Narayan, assistant professor of urology at Emory University School of Medicine and director of urologic oncology at Grady Memorial Hospital, said in an interview with CURE®. “But the actual causation of this increased risk has not formally been established. I think that as we see more individuals who may have been exposed to Agent Orange, veterans and others, we’re beginning to see persistently higher rates of bladder cancer.”

“If (patients with bladder cancer) were in the Vietnam War (or potentially certain other places where Agent Orange was used or tested), it would be presumed that their bladder cancer was due to their service, and they could apply for benefits that could include compensation and increased health care eligibility in the Veterans Health Administration,” according to a VA spokesperson.

Narayan added that proving causation between Agent Orange exposure and bladder cancer is difficult to do on a population level, although knowing about this hypothesis may help patients in their families regardless.

“There are so many other factors that an individual’s exposed to in their lives, whether that be environmental exposures, things they consume, places where they live or grow up and genetic factors as well,” Narayan said. “To take something like a singular exposure from a while back and link it conclusively will likely be very difficult. That being said, if you see trends in populations, you can draw inferences, and this is how many of our hypotheses are generated. And at least being aware of the fact that a link is possible makes it important for patients and families to be aware of just so that they can look to be screened for bladder cancer, and then seek care early, particularly if they have signs or symptoms of the condition.”

‘Fights That Have Been Going on for Years’

James R. Scott Jr., enrolled in the Army in 1967 and started in Fort Monroe, Virginia before going on his overseas tour of duty, which included Vietnam, Thailand, Cambodia and Laos, where he suspects he was exposed to Agent Orange. He thinks the herbicide is related to his bladder cancer diagnosis later in his life. Scott said that while he was on his tour of duty, there were no warnings on the potential harm that Agent Orange may cause.

“Agent Orange was housed mainly in the surrounding countries like Thailand, Cambodia and Laos and not stored so much in volume, and it was (flown into Vietnam),” Scott said. “(There were) a lot of ways to get exposed.”

Scott originally did not receive benefits from the VA when he was diagnosed with bladder cancer in 2015 at age 69 because the Agency did not recognize bladder cancer as a disease related to Agent Orange exposure until this recent decision.

“I talked with my urologist, and he said, ‘It just doesn’t make sense, because whatever goes through your system … goes through your bladder to get to the prostate,” Scott said. “That was one of the fights that have been going on for years and trying to get the government to acknowledge the fact that if it affects the prostate, it had to affect the bladder as well.”

Going back to Scott’s diagnosis, he suspected something was wrong when he saw blood in his urine, which a primary care doctor diagnosed as a urinary tract infection. The infection would be treated, but then blood would return in Scott’s urine for about a year.

“One day I went in (the doctor’s office), and my primary care doctor asked for a urine sample,” Scott said. “He came running back in the room carrying the little jar and he says, ‘Guess what? You have some urine in your blood.”

That’s when his primary care doctor sent him to a urologist for testing, which resulted in the discovery of a tumor the size of an orange, among two dozen other tumors in his bladder.

“(The doctors) told me at that point that my chances of the cancer coming back into my bladder was 100%, so they said I could have the operation to remove my bladder now or later,” Scott said. “I figured at the age of 69, it probably would be better for me to do it than when I was 89, so I opted for the surgery.”

He was also told that if the cancer returned, it would most likely go through the walls of his bladder and metastasize somewhere else in the body, which makes the disease more difficult to control. Scott underwent laparoscopic surgery to remove his bladder after undergoing chemotherapy.

“Losing your bladder is quite a challenge because regardless of which diversionary system you opt with, it’s not a turnkey operation,” Scott said. “You end up taking a lot of time adjusting to your new normal.”

Scott has been cancer free for over five years, during which he spent his time advocating for patients with bladder cancer, especially veterans. In conjunction with the Bladder Cancer Advocacy Network, he also traveled to Capitol Hill in Washington, D.C., to speak about his journey with bladder cancer.

“After my surgery, my motivation to get involved, help someone else and to show thanks was immediate,” Scott said. “I knew that God had given me a test so that I’d have a testimony to help someone else.”

Scott mentioned that the VA did not pay for his cancer treatment or surgery, but approximately one year after his surgery, he went to the VA and started receiving compensation for his disability.

“Had I not had good insurance, Lord only knows where I would be today,” Scott added. “That’s the thing that hurts because there are so many former military people out there who do not have good insurance; they possibly did not get any treatment. They may have just died.”

‘Way Overdue, But So Appreciated’

After finding out that the VA will now be accepting bladder cancer as a condition potentially related to Agent Orange exposure, Scott mentioned that he’s extremely excited, although he said it’s not fair that it took so long.

“This is way overdue but so appreciated,” Scott said. “If it had to happen, it happened now. But it really hurts to think about all the GIs and their families who suffered. ... People who go home with any type of ailment or deformity because of war, they live with that for the rest of their lives, but not just them, their family, their friends. It changes their whole world.”

Not only can this change the lives of patients and their families, but also the care paradigm as a whole.

“The fact that this is now an established part of the care paradigm allows patients and physicians (to) hopefully improve the documentation that occurs, allow for better research into who exactly may be exposed and how this comes about,” Narayan said. “When I was a trainee, I was involved in the project where we looked at cohort of patients who had bladder cancer, and we looked back to see which of these patients had Agent Orange exposure. One of the challenges is, it's very hard to track down who clearly may or may not have exposure, and any effort to try and make that better will go a long way to improving the treatments that are offered and the diagnoses that are conducted.”

Scott noted that he received a letter from the VA dated June 21, 2021, which detailed how they are reaching out to surviving spouses, children and parents, among others, to help people get their benefits related to bladder cancer. The letter also included instructions on what patients and their families should do whether they were already receiving VA benefits or not.

The VA spokesperson added some information on how Vietnam veterans can file a claim.

“We are grateful for the service and sacrifice of the men and women who fought in the Vietnam War,” a VA spokesperson said. “We encourage Vietnam veterans (and other veterans who may be eligible) to enroll in the Agent Orange Registry if they haven’t done so already. The registry is not connected to the compensation or health care system; however, those eligible may opt into a registry examination at no cost to the veteran.”

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