CCK Founding Partner Robert Chisholm interviews military toxic exposure expert Dr. Victoria Cassano to discuss Agent Orange, burn pits, and Camp Lejuene.
For more information about Dr. Cassano and military exposures, read our BLOG here.
Robert: Good afternoon, we’re live from San Diego and we’re talking today with Dr. Cassano and Dr. Cassano has expertise in environmental science, really dealing with toxic exposures. So, I’d like you to start off by telling me about your sort of your educational history, you could start with that.
Dr. Cassano: Well, I went to college up in Westchester and then did graduate work in Human Genetics at Columbia. And then decided, at that point, I had a choice of where to go to medical school and I decided to do the Uniformed Services University in the health sciences. Which is a medical school for all of the– not only the armed forces but also the Coast Guard and the Public Health Service.
Robert: And so, after you completed all your medical training, were you in the service for a period of time as well?
Dr. Cassano: I was in the service for 24 years, I first trained as an Undersea Medical Officer which included diving and submarine medicine. And then, did my residency at the University of Michigan in Occupational Environmental Medicine.
Robert: Okay, so I’d like to sort of focus on the obviously Occupational Environmental Medicine. Because a lot of our service men and women have been exposed to things — depending on which period of war we’re talking about, correct? And so, one of the things I wanted to talk to you about is there is this list of presumptive conditions that after a really long drawn out sort of legal battle and political battle that VA now recognizes that if someone had boots on the ground in Vietnam that– and they later develop something, for example like lung cancer, it’s automatically presumed. But there are other cancers that are not presumptive and those veterans would have to use what we call a medical nexus opinion to show that their exposure led to this– Agent Orange exposure, whatever chemical or herbicide it was, led to the particular disease. Could you talk a little bit about those kinds of medical exposures and disabilities?
Dr. Cassano: Well, as I alluded to earlier, Agent Orange is sort of the scapegoat for everything bad that happened in Vietnam. And, so when you look at the exposures and you look at the medical conditions that people have developed, the first thing you have to do is look at the medical literature because that’s constantly evolving in order to determine whether there is scientific grounds for saying that a person who was exposed to Agent Orange or the arsenicals that were in some of the other herbicides could possibly have it related to this medical condition. So, that’s the first step, at which point you then have to interweave what that individual’s medical history was, what that individual’s exposure history was and what his other risk factors were to develop this particular disease and you’ve got to weave all this into a cogent argument for the nexus.
Robert: And so, in these kinds of situations, it’s going to be really important obviously to take a detailed medical history or to have it in the records already, if it’s just a records review. So that you can do the analysis and it’s not something you can say well “Everyone who’s exposed to Agent Orange has this” you have to really dig in and do it on a case-by-case basis. So, you also mentioned that it’s just Agent Orange is—I’m going to try to say the word correctly, arsenicals and chemical exposures didn’t just happen in Vietnam obviously. We know for example that there other occurrences in Thailand. And so for those veterans, there’s a working rule but it’s not a presumption in a sense.
Dr. Cassano: Exactly.
Robert: And so those individuals need a specific medical opinion as well. And so, I don’t mean to be flippant with this question but why are you the one that’s qualified to do these kinds of opinions? What is it about your history and training that–
Dr. Cassano: I’m probably not the only person that’s qualified to do this but I think I meet criteria that a lot of people don’t. Number one, I was in the military for 24 years. I was a physician in the military, was an occupational physician in the military. So, I took care of people that had all sorts of exposures. Now, I was a little– I’m a little young still to have been a doctor in Vietnam but if you understand the military, you understand how people are exposed. You understand the fact that precautions aren’t taken that might normally be taken. When you’re trying to dodge bullets and grenades and IEDs, you’re not particularly concerned about how much of that diesel exhaust you’re breathing. And that becomes a problem when veterans try to reconstruct their history, they say “You didn’t complain about this when you came back from overseas”, “No, I had few other things on my mind.” So, I understand that and I understand where to go in order to find out what somebody actually did. I’ll look at what’s called the military occupational specialty, I’ll look at a Navy enlisted classification. And then, when I go through a record I just don’t look at the DD 214. I look at every single solitary organization that they were assigned to and pretty much read through what are called FITREPs or enlisted evals in order to see what this guy actually did because most of the time, especially in the Navy, you’re working outside of your MOS for a lot of what you do. The second thing is I know the rules. I know the regs and when you’ve got that kind of expertise, I can write that into a medical opinion and in some way, not to take your job away from you. I never want to do that but it really helps when you’re talking about something, let’s say chloracne, and they say, “Well, you don’t have a diagnosis of chloracne” and I’ll say, well because nobody understood that there was a relationship back then. However, that’s why the rule says any acne form disorder that could be construed as chloracne. And so, when you feed that back to the RO in a medical opinion, they have to pay attention to it. It’s not that I think they were trying to– I think they’re good people working at VA, I really do. And they try very hard–
Robert: And I agree with that. It’s a very difficult task and in these kinds of cases in particular they don’t– they might not have the expertise they need.
Dr. Cassano: And they rely on– you’re probably going to get into this next but they rely on people on the medical side that don’t have the expertise to sort it out for them.
Robert: Right, and so that was exactly where I wanted to go next. Sometimes VA will do a compensation and pension examination. Sometimes that could be done by a nurse practitioner, a physician’s assistant and they’re giving opinions on exposure and disabilities related to those exposures. And so, what is your sort of general impression of what– when you’re reviewing a record and you see one of those opinions? What is your role?
Dr. Cassano: Well, it depends on, and again the rules say that it doesn’t matter who does the opinion, it’s how they rationalize the result. And so, I sometimes sound like I’m hard on mid-level providers but the fact of the matter is if individuals do not have at least basic expertise in occupational medicine and toxicology, they can’t possibly sort this out properly unless they’re going to spend an inordinate amount of time reviewing the peer-reviewed literature that they may not actually have access to where they’re at. General references such as UpToDate or the Mayo Clinic website or Cleveland Clinic website are talking– when they talk about risk factors and they talk about etiology of a disease, they’re looking at it from the general public perspective, they’re not looking at it from specific– for specific cohorts. So, if you don’t see Agent Orange in UpToDate or on the Mayo Clinic website, it doesn’t mean that it doesn’t exist.
Robert: Right, so you may have to have access to different things. So that brings up another important question is– it isn’t just reviewing the records, you’re also doing research, medical research into the most current articles and thoughts going and processes going into this sort of analysis of what kind of disabilities are related to what kinds of exposures.
Dr. Cassano: Yes, exactly. You have to be doing that, I mean the IOM reports which we count on a lot but which are– were primarily used to determine presumptions for the VA. Remember those are consensus documents and they may place more weight on a certain set of studies than they do on another. And, there’s a lot of discussion and compromise and back and forth to get to a consensus opinion as what they’re going to say as far as limited or suggestive evidence or definitive evidence or no evidence. And so, you always have to go beyond that, you actually have to look at some of the papers that they’ve reviewed and I’ve done that on a couple of times and I’ve taken exception in some instances to some of their interpretations. And then, you have to look at the literature that’s been published since they started their studies because if the report comes out in 2014, they haven’t looked at literature since 2013. So–
Robert: There’s more —
Dr. Cassano: There’s more up to date stuff.
Robert: Okay. So, if I could transition to the sort of– one of the current issues that we’re facing with some of our clients are those who were exposed to burn pits and some of the disabilities that are related to those burn pits. And right now there’s no presumptions for burn pit cases.
Dr. Cassano: Exactly.
Robert: So, how could you go into doing an analysis, a medical opinion if you will for someone who’s exposed to a burn pit? What are the factors you’re going to look at? Because I’m guessing you don’t have real-time air samples, for example.
Dr. Cassano: Well, there are some sampling data that the DoD did, they did it– spot testing, there’s some question about whether the burn pits were actually functioning when they were testing or whether they were testing upwind or downwind or whatever. But you can at least get an idea of what kind of chemicals were being thrown into the atmosphere there. You can– and then you have to listen to the individual service members about what their experiences were. I’ve had veterans who have said, “Yes, like the air we had little space air conditioners and we had to change the filter just about every other day because it would get caught. There was soot everywhere. When I would come back from running, I would have black soot in my nose.” And then you have to look at where they worked, the proximity to the burn pit, you have to look at where they lived and the proximity to the burn pit. And then you have to do that same literature review of, okay it says that there were, for instance, there were dioxins that were present in the atmosphere around the burn pits. How much do I think this person was exposed to that air? And then, of course, you get into the issue of dose which is always impossible to deal with. Because you don’t have any good dosage information. And so you have to use these sort of indirect measures of how much soot, how much did—was your throat irritated? Were your eyes irritated?
Robert: And then would you also get genetic predisposition, those kinds of factors, family history?
Dr. Cassano: Well, you look at family history but– as I said many times unless you’ve got a true genetic disease, hemophilia, Huntington’s chorea, one of those diseases, genetics predisposes somebody to develop a disease. Possibly, depending on their genetics. So, because they may have one enzyme and one pathway that is more susceptible to let’s say Agent Orange or whatever. So, those are the people that either develop disease earlier or develop more severe disease or these are the people that actually will develop the disease over a long period of time. So, but it’s never a rule out for the other toxicant and the reason for that is toxic–
Robert: So that’s important when you say it never excludes the possibility or the probability depending that the exposure in service caused the condition.
Dr. Cassano: Yes and part of the problem is it says “did it cause.” It doesn’t in other workers comp fields, substantially contributed to is the language–
Robert: Here it’s a 50-50 proposition. I mean, it’s a more generous standard that you have to meet. I mean a less generous.
Dr. Cassano: Less generous.
Robert: Less generous.
Dr. Cassano: Well and it’s–
Robert: More generous than the veterans.
Dr. Cassano: There’s no—it basically says that this– there’s lots of ways to interpret it. The way most people interpret it is this caused it alone to the exclusion of other toxicants. You know and most of the time, that’s not how toxicants work. Everybody does– and I think I’ve used this it’s not like which sperm gets to the egg first. It’s like smoking says, “I was here first, I get to do all of the damage and you other guys go home.” It doesn’t work like that. They’re all working their damage and they’re all causing this disease in concert. If you look at things like smoking and asbestos, it’s actually worse than that, it’s not just added to the effects, they’re synergistic, they work together to cause lung cancer.
Robert: The last topic I want to talk about is Camp Lejuene.
Dr. Cassano: Okay.
Robert: And so, we now have these presumptive conditions due to the exposure in the water. Were you involved at all at any of that being promulgated?
Dr. Cassano: I’m thinking back. I think I was at the very beginning of it when the whole Camp Lejeune thing came up. And, I did have to evaluate some of the literature. I think I was back over at DoD when the presumptions got promulgated.
Robert: So, are there– in addition to the conditions that are on the list, are there other things that you believe could be caused by Camp Lejuene that VA doesn’t recognize as presumptive? I guess that’s really the other question I have.
Dr. Cassano: I certainly, I mean– first of all there were 15 conditions on the list that ATSDR put out and then subsequently Academy of Medicine put forward as limited or suggested evidence of causation. Definitely, TCE and PCE now. I think bladder– excuse me I’m getting confused–
Robert: That’s okay.
Dr. Cassano: It’s either bladder cancer or kidney cancer that is presumptive. From my perspective, I can make a case for either one.
Dr. Cassano: That’s one. The other one is I think immunological derangement and you see that both on the immunosuppression side and on the autoimmune disease side.
Robert: So, give me an example of an autoimmune disease you’re talking about.
Dr. Cassano: Chronic Inflammatory Demyelinating Polyneuropathy is one that I have, on a case-by-case basis, done a medical opinion on. And, scleroderma is presumptive. Scleroderma is an autoimmune disease. There’s very little difference in how one autoimmune disease is caused versus other autoimmune diseases. It happens to just be the target tissue that may be different. So, depending on what the autoimmune disease is and what kind of literature is out there, you can sometimes make a good medical nexus. I cannot do it for systemic lupus erythematosus, SLE. There’s just too many competing factors in there and too many variables to be able to do that.
Robert: So, let’s suppose a veteran has a type of cancer that isn’t recognized as presumptive either due to Camp Lejeune or due to Agent Orange. What is it you would want to see from them to sort of–?
Dr. Cassano: What I need to see is number one, what they did. Let’s say, if they were in Vietnam it usually helps to see what they were doing in Vietnam when you don’t– when you’re not covered by the presumption. Where they were, how long they were there, what else were they exposed to? I see so many times how these guys were construction battalion guys and so they’re kicking up dust and dirt all over the place, they’re digging in it. They’re also exposed to diesel exhaust which is 1.5% by weight benzene, which is another exposure. They’re not protected, they’re not taking any precautions at all. So, I need all of that. I need– what helps greatly in cancer cases is the type of cancer the person has. When you look at esophageal cancer, now esophageal cancer is not one that is presumptive. There is some literature on especially gastroesophageal junction cancers that are associated with exposure to dioxins. And, so I need to know where the cancer was, if the guys– especially if somebody smoked. If somebody smoked and they’ve got an upper esophageal squamous cell carcinoma, it’s going to be really hard for me to say that this was due to Agent Orange but if it’s lower down the tract and it’s an adenocarcinoma, whether or not the person had Barrett’s esophagus which some people bring in to play, I can usually make a case for that.
Robert: So, what their job was, what they were exposed to, what the cancer is–
Dr. Cassano: Location of the cancer. And the other risk factors.
Robert: And the other risk factors. The last thing I wanted to say is talk about latency periods if that’s the right word to characterize this. Because these veterans in Vietnam served many many years ago and they’re still developing these cancers decades later. Is it possible that that will hold true, we won’t know the full picture of like the veterans that were exposed to burn pits for years and years to come? Or is the science getting better so you learn faster I guess that’s really what I think.
Dr. Cassano: There’s no way– there’s no way to hasten the– I mean somebody is either going to develop a disease– they’re going to develop a disease when they develop a disease and unfortunately, when you look at epidemiology, you need more people with the disease in order to be able to have enough of a group–
Robert: To make an informed opinion.
Dr. Cassano: To make an informed opinion. What I think, maybe not at VA but in other arenas, what I think people are getting better at, number one is being a little bit more positive toward animal data and utilizing animal data in a more predictive way. I think we’re also better at looking at analogous chemicals and so you look at PCVs versus dioxins. PCVs and dioxins are on a sort of a continuum. PCVs are not a dioxin, they’re considered a dioxin-like compound but they are halogenated. They are halogenated hydrocarbon product that has a phenyl diphenyl group. And so they’re very similar in their effect. PCVs do have additional effects because of some of the other moieties on it than some of the dioxins do. But definitely TCDD which was the contaminant in 2,4,5-T is the most potent dioxin out there.
Robert: And that was part of the Agent Orange?
Dr. Cassano: That was part of the Agent Orange. But all of them, 2,4,5-T is now banned, 2,4-D is not but probably will be, because they all have similar effects. It’s just how potent they are as a toxicant.
Robert: Okay. Is there anything else you’d like to share before we finish up today?
Dr. Cassano: Anything else you want to ask me, I don’t know. I don’t–
Robert: I don’t think so. I really appreciate your time today, we really appreciate your time so thank you.
Dr. Cassano: It’s been fun. Thank you, appreciate it.