Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cancer, Brain


Related Terms

  • Astrocytoma
  • Brain Cancer
  • Brain Neoplasm
  • Glioblastoma
  • Glioma
  • Malignant Brain Tumor
  • Malignant Neoplasm of the Brain

Differential Diagnosis

Specialists

  • Neurologist
  • Neurosurgeon
  • Oncologist
  • Radiologist
  • Radiology Oncologist

Comorbid Conditions

Factors Influencing Duration

All the factors that determine the type of treatment will also influence the length of disability because they determine the ultimate prognosis. Those factors include cell type and degree of malignancy, tissue involvement, location of the tumor, extent of cancer spread (metastasis), overall health and medical history, presence of complications, likelihood of recurrence, and the individual's tolerance for specific medications, procedures, and therapies. Complications of surgical treatments or shunting can prolong recovery.

Medical Codes

ICD-9-CM:
191.0 - Malignant Neoplasm of Brain; Cerebrum, except Lobes and Ventricles; Basal Ganglia; Cerebral Cortex; Corpus Striatum; Globus Pallidus; Hypothalamus; Thalamus
191.1 - Malignant Neoplasm of Brain; Frontal Lobe
191.2 - Malignant Neoplasm of Brain; Temporal Lobe, Hippocampus, Uncus
191.3 - Malignant Neoplasm of Brain; Parietal Lobe
191.4 - Malignant Neoplasm of Brain; Occipital Lobe
191.5 - Malignant Neoplasm of Brain; Ventricles, Choroid Plexus, Floor of Ventricle
191.6 - Malignant Neoplasm of Brain; Cerebellum NOS, Cerebellopontine Angle
191.7 - Malignant Neoplasm of Brain; Brain Stem; Cerebral Peduncle; Medulla Oblongata; Midbrain; Pons
191.8 - Malignant Neoplasm of Brain; Other Parts of Brain; Corpus Callosum; Tapetum
191.9 - Brain, Unspecified; Cranial Fossa NOS
198.3 - Secondary Malignant Neoplasm of other Specified Sites; Brain and Spinal Cord
225.0 - Benign Neoplasm of Brain and Other Parts of Nervous System; Brain
239.6 - Neoplasm of Unspecified Nature of Brain

Overview

Brain cancer is a malignant tumor (or tumors) that originates from cells in the central nervous system (CNS) tissue of the brain (primary brain cancer) or migrates to brain cells from another cancer in a distant organ (secondary or metastatic brain cancer).

Tumors that occur in the brain can be noncancerous (benign) or cancerous (malignant). Unlike malignant tumors, benign tumors do not invade other tissue. However, benign tumors can be just as dangerous over time as malignant tumors when they begin to increase the amount of mass in the skull, compress vital structures, and cause serious symptoms and complications.

Brain tumors invade, infiltrate, and replace normal CNS tissue in the brain and, as a result, produce neurological symptoms. Even a small tumor can damage neural pathways in the brain. The effects of tumor growth include swelling (edema) and fluid accumulation (hydrocephalus), which together can increase intracranial pressure (ICP), impairing brain perfusion and CNS activities. However, unlike lung, colon, and breast cancers, primary brain cancers rarely spread (metastasize) to other organs. Although treatment can sometimes prolong life, death usually occurs as a result of uncontrolled growth of the tumor within the confines of the skull. As the tumor compresses vital brain centers controlling consciousness and bodily functions, the individual lapses into coma, and breathing ultimately stops (respiratory arrest).

Primary brain tumors are classified by cell type of origin and by how malignant the cells appear when examined using histopathology techniques (histological grade). The location of the tumor and whether the tumor spreads throughout the cerebrospinal fluid bathing the brain may also help classify some brain tumors. Standardized staging of the tumor is not done, as it is with malignancies in other organs. Glial tumors originate from connecting and supporting brain cells called glia. These tumors include astrocytomas, ependymomas, oligodendrogliomas, mixed tumors, medulloblastomas, and the highly malignant glioblastoma multiforme, which is the most common malignant brain tumor. Tumors derived from cells other than glia include pineal parenchymal tumors, germ cell tumors, craniopharyngiomas, meningiomas, and choroid plexus tumors. Gliomas, metastatic tumors, meningiomas, pituitary adenomas, and acoustic neuromas represent 95% of all brain tumors diagnosed (Huff). Primary malignant tumors represent 2% of all cancer in adults; many more secondary brain tumors are diagnosed than primary tumors (Chandana).

Incidence and Prevalence: The estimated incidence rate for primary brain tumors ranges from 7 to 19.1 new cases of brain cancer per 100,000 people each year. The incidence is higher for metastatic brain tumors; more than 100,000 individuals die annually of secondary brain tumors (Huff). Estimates issued by the American Cancer Society for 2010 included 22,020 new cases of primary brain and CNS tumors and 13,140 deaths each year ("Detailed Guide"); the incidence is increasing, as shown by an incidence rate of 6.4 cases per 100,000 people in 2003, compared to a rate of 5.85 in 1975 (Chandana).

The exact international incidence is not known because data are not collected by all countries. Developed countries report the highest incidence rates, but that may be related to more efficient data collection. Threefold differences in incidence have been reported between countries and sometimes between ethnic groups (Huff).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for developing a primary tumor include exposure to x-rays (radiation), electromagnetic fields, chemicals such as vinyl chloride (associated with rubber manufacturing, dye making, and other industries), or solvents such as benzene; rare genetic conditions (e.g., neurofibromatosis and Von Hippel-Lindau disease); and prior head injury. Risk due to cellular telephone use is controversial and may be associated with long-term and frequent use. Gene mutations are believed to be involved in tumor development, but the exact mechanism is unclear.

Individuals with a history of lung, breast, colon, kidney, or skin (melanoma) cancer are also at increased risk for brain cancer.

Slightly more men are diagnosed with brain malignancies than women, with a male-female ratio of 1.5 to 1; however, women are slightly more likely to be diagnosed with meningioma and pituitary adenoma (Huff). The lifetime risk for brain tumor is 0.65% in males and 0.5% in females, with a peak incidence occurring between ages 65 and 79 (Chandana).

Brain tumors are the most frequently diagnosed solid tumor in children and are the second-most-frequent malignancy in children, after leukemia.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may complain of a headache, a change in type or location of headache, nausea, and vomiting. Other symptoms may include drowsiness, lethargy, personality changes, emotional changes, impaired cognitive function, memory loss, impaired sense of smell, vision loss, hearing loss, equilibrium disorders, gait difficulties, and seizures. Depending on the tumor location, individuals may complain of localized weakness, numbness, impaired speech, or other neurological symptoms. A history of prior illnesses, head injuries, medications, exposure to toxins, and a family history of brain tumor may be helpful in diagnosing primary tumors.

Physical exam: An examination using an ophthalmoscope (an instrument used to view the inside of the eye) may reveal swelling of the optic nerve, indicating increased ICP. A complete neurological exam is usually done, testing the senses (including vision, smell, touch, and taste), motor responses, muscle strength, coordination, reflex response, and autonomic responses (increases or decreases in pulse, breathing, sweating in response to stimuli). If a tumor is present, abnormalities such as neurological deficit are frequently seen on a neurological exam, depending on the location of the tumor. Abnormalities may be observed in the individual's vision, if a cancerous tumor is present in the occipital lobe of the brain, or in motor responses and coordination, if a cancerous tumor is present in the brain stem or cerebellum (a brain structure toward the back of the skull involved in coordination and movement). A neurological exam may be relatively normal when the tumor is located in the frontal lobes of the brain; however, loss of the sense of smell (anosmia) may be noted if tested.

Tests: Routine blood studies are needed to evaluate conditions that may be associated with brain tumors, including bleeding disturbances, metabolic imbalances, and elevation of certain hormones (e.g., antidiuretic hormone). A complete blood count (CBC), coagulation studies, electrolyte analysis, and a complete metabolic panel are typically performed on hospital admission. Laboratory tests may also help rule out other possible diagnoses with similar symptoms such as stroke (cerebrovascular accident, cerebral hemorrhage) or metabolic dysfunction.

Neuroimaging studies are necessary when an intracranial tumor is suspected in individuals who have had mental status changes or seizures. Contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) is essential for locating a tumor and often for identifying the type of tumor by its characteristics. MRI is the currently preferred initial diagnostic imaging modality for suspected brain tumor because it allows more detailed visualization. Use of radioactive contrast injected into a vein during these procedures makes the tumor size and density more visible. Noncontrast MRI is useful in individuals who are allergic to contrast material; it allows detailed visualization of tissue and helps to identify tumor type, especially acoustic neuromas and hemorrhagic tumors. Positron emission tomography (PET) may help to evaluate brain function and cell growth by producing images of chemical and physical changes in the brain. PET may also locate a tumor and determine metastatic and recurrent brain cancer at earlier stages than MRI or CT scan. Skull x-ray is rarely necessary except in tumors such as meningiomas that may invade or press against the bone. Lumbar puncture may be done in some cases to examine cerebrospinal fluid for the presence of malignant cells.

A surgical biopsy is the only method able to precisely diagnose primary and secondary brain tumors; biopsy is usually performed at the time of surgery to remove the tumor. Before surgery, a radiographic study with injection of a radio-opaque contrast agent in selected blood vessels (arteriogram or angiogram) may be needed to determine which blood vessels supply the tumor. In individuals with seizures, an electroencephalogram (EEG) is usually indicated. After biopsy, the type of tumor may be determined by the type or types of cells seen under microscopic examination of a specially stained sample of tumor tissue (histopathologic examination).

If biopsy confirms that the brain tumor is metastatic, secondary to a tumor in a distant organ, imaging studies may be required to locate that tumor and to determine the stage of the cancer, if that has not already been done. Staging of the primary tumor that has metastasized to the brain will be an important indication of the degree of metastasis and the prognosis for the individual. Staging is expressed as stages I, II, III, or IV, with lower numerical values indicating a less invasive cancer and a better prognosis.

Source: Medical Disability Advisor



Treatment

Treatment depends on the characteristics of the cancer, including cell and tissue type, the location and size of the tumor, and the degree of metastasis if the tumor is secondary. Treatment also depends on the individual's overall health, age, medical history, and tolerance for specific medications, as well as the appropriateness of procedures, therapies, and expectations for the course of the disease.

Surgery is the first choice for treatment and is usually followed by radiation and anticancer drugs (chemotherapy). Tumors may be removed completely (resected) or reduced in size (debulked) to reduce intracranial pressure; the decision to resect is made based on the tumor location and size, histopathology, and the presence of comorbid conditions. Current surgical techniques allow access to deeply embedded tumors that were previously inaccessible. For example, stereotactic and frameless stereotactic surgery often allows more precise localization of the tumor. In stereotactic surgery, a needle is inserted into the skull while simultaneous 3D images of the brain and the tumor are taken with either a CT scan or MRI to guide the procedure. The tumor is aspirated through the needle. Larger tumors cannot be resected with this technique. The surgery can be done with or without a frame. If the procedure is done with a "halo-shaped" frame, it is first screwed into the outside of the skull and stays on the patient‘s head during the procedure. In patients whose tumors are so large that they prevent cerebrospinal fluid from draining and thus cause elevated intracranial pressure, a shunt is inserted to drain the fluid and decrease the pressure. Intraoperative radiotherapy is used in conjunction with stereotactic surgery (stereotactic radiosurgery), delivering either a single high dose or two or three large doses of radiation (Chandana).

Chemotherapy may be given by mouth or by injection into a vein. To deliver chemotherapy more directly to the tumor, it is sometimes injected into an artery supplying the tumor, or more commonly into the cerebrospinal fluid through shunt tubing accessible from the skull (Ommaya reservoir). Clinical trials are evaluating the safety and efficacy of specific, new chemotherapy agents being delivered directly to the tumor through a catheter; although the technique has shown promise, more research is needed before conclusions can be made. Newer chemotherapy agents (e.g., temozolomide, erlotinib, gefitinib, and imatinib) combined with radiotherapy are producing good results and increased survival, especially with glioblastoma multiforme (Chandana). These drugs target either epidermal and platelet-derived growth factor receptors or vascular endothelial growth factor. A specific gene (methyl guanin and methyl transferase, or MGMT) is targeted or "silenced" by chemotherapeutic agents; this treatment is associated with increased survival (Chandana).

Standard radiation therapy consists of using 25 to 35 daily external-beam radiation treatments over a 5- to 7-week period (Chandana). Different methods of administering radiation therapy are also being evaluated (e.g., hyperfractionated irradiation, accelerated fraction radiation, radiosensitizers, hyperthermia, interstitial brachytherapy, intraoperative radiation therapy). Brachytherapy places radioactive material ("seeds") directly into the tumor rather than directing external radioactive beams to the tumor. This technique is showing promise and has been FDA-approved for use in treating certain types of cancer, notably prostate, cervicouterine, and head and neck cancers. Its use in treating tumors of other types is expected to increase.

Steroids (adrenal cortical hormones or glucocorticoids) are often given to reduce brain swelling and help increase alertness. Anticonvulsants may be needed in some individuals with seizures, and are sometimes given prophylactically around the time of surgery to prevent this complication. However, the use of anticonvulsants is not encouraged by the American Academy of Neurology in individuals with newly diagnosed brain tumors. Neurologists in the organization advise gradually reducing the dosage of anticonvulsants in patients who receive them and discontinuing them altogether after surgery (Huff).

Aggressive malignant tumors are often treated with a combination of surgery and radiation therapy, which slows their progress. However, this combined approach is not an option when the radiotherapy dosage needed to kill cancer cells risks damaging the sensitive brain tissues. Aggressive malignant tumors are also treated with a combination of surgery and chemotherapy. Newer cytotoxic drugs directed to specific targets are making chemotherapy a more viable treatment option.

Source: Medical Disability Advisor



Prognosis

The outcome for an individual with brain cancer depends on the cell type, how malignant the cells appear under the microscope (histological grade), how early the cancerous tumor is detected, where the tumor is located in the brain, how much of the tumor can be removed by surgery, and the individual's response to treatment.

Primary cancers of the brain and CNS result in death in approximately 13,100 individuals annually (Huff). Without radiation therapy, individuals with metastatic brain tumors have a 1-month mean life expectancy; radiation therapy increases expected survival to 4 to 6 months. Most individuals with metastatic cancer do not die from damage related to the secondary brain tumor but from progression of the tumor of origin (Huff). Tumors that result in seizures are predictive of neurologic dysfunction and a 6-month life expectancy (Huff).

Historically, radiation and chemotherapy have met with limited success because the dosage of radiation needed to kill cancer cells in the brain also damages sensitive brain tissues and because cancer cells in the brain can become resistant to chemotherapy drugs. Newer chemotherapy drugs, however, target specific tumor-related targets (receptors), making them more effective in retarding tumor growth (Chandana). Modern dosing schedules for radiation and coordinated use of steroids have reduced acute toxic reactions to radiotherapy (Huff).

Many malignant brain tumors tend to recur within 6 to 12 months after the initial diagnosis. The five-year survival rate for all people with brain cancer varies with age: 55% for individuals aged 15 to 44, 16% for individuals aged 45 to 64, and 5% for those over 65 (“Detailed Guide”).

No cure is available for individuals with metastatic brain cancer, and the median survival period is less than 12 months. About 100,000 deaths are attributed to metastatic brain cancer annually (Huff).

Individuals who have survived malignant brain tumors and who are able to return to work report high levels of work limitations and time off. A study showed that workers with brain tumors had symptoms such as depression, fatigue, and limitations in cognitive thinking and problem solving that kept them from being productive workers (Feuerstein).

Source: Medical Disability Advisor



Rehabilitation

Individuals diagnosed with brain cancer require physical and occupational therapy on an inpatient basis and may require home care or outpatient therapy. Individuals may also require speech therapy. The extent and types of therapy necessary vary among individuals, depending upon the location of the tumor, how localized the tumor is, and the treatment required. Therapy focuses on the following areas: improving communication, maintaining range of motion, increasing strength, improving coordination, improving balance, and improving functional abilities such as gait.

To improve communication, speech therapists teach individuals specific lip, tongue, and facial muscle positions that help to clarify speech. Individuals with the inability to communicate orally may learn to communicate through a variety of other methods.

Individuals may experience weakness and decreased function in their arms and/or legs, impaired fine motor coordination, or problems with balance. A comprehensive therapy program is critical to improving and maintaining functional abilities. Occupational and physical therapists instruct individuals and their family members how to safely stretch and strengthen the arms and legs to promote range of motion and increase fine motor coordination. Exercises to improve sitting and standing balance are essential in preserving the ability to walk.

Individuals with end-stage brain cancer may require palliative therapy, in which the primary focus is pain control. Rehabilitation nurses, physical therapists, and occupational therapists all provide palliative care services.

Individuals diagnosed with cancer may find it beneficial to undergo psychological counseling either on an individual basis or in a support group setting. Psychological well-being is essential to physical health, and counseling can help individuals deal with issues such as fear of dying and provide a forum for voicing concerns about topics such as cancer treatment and side effects, nutrition, and decreased energy levels.

Source: Medical Disability Advisor



Complications

Possible complications of brain cancer include neurologic impairment (deficit) such as paralysis or language disturbance, seizures, increased risk of blood clots (thromboembolic complications), brain herniation, cerebrovascular accident with the possibility of hemorrhage at the tumor site, and coma. Some surgical treatments and radiation therapy may lead to destruction or impairment of other brain structures, causing additional complications. If the patient has had a shunt placed, the complications of shunting include bleeding, infection, malfunction, and seizures.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Possible changes in cognition, coordination, strength, vision, and other neurologic functions may necessitate specific work restrictions and accommodations. Some job requirements may be impossible for individuals with brain cancer, and permanent disability is not unusual.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual complain of headache, nausea, and vomiting? Have personality changes, drowsiness, impaired cognitive function, or seizures been noted?
  • Was a complete neurological exam done? Ophthalmic examination?
  • Have other possible diagnoses with similar symptoms been ruled out?
  • Have CT and/or MRI confirmed the existence and location of a brain mass?
  • Have routine blood tests such as CBC, coagulation studies, electrolyte analysis, and a complete metabolic panel been done to evaluate possible bleeding disturbances, metabolic imbalances, and elevation in hormones associated with brain tumors?
  • Before surgery, was an arteriogram done to help determine blood supply to the tumor, facilitating removal?
  • Was the specific cell type and degree of malignancy confirmed by histopathologic examination of surgically removed tissue?
  • Is the brain cancer primary or metastatic? If metastatic, was the tumor of origin treated? What is the stage (I, II, III, IV) of the tumor of origin (i.e., how metastatic)?
  • Is there suspicion that the tumor has invaded cerebrospinal fluid? Is it safe to remove cerebrospinal fluid by lumbar puncture to look for malignant cells, or would this cause brain herniation?

Regarding treatment:

  • Can the entire tumor be removed without compromising neighboring structures, or should surgery be limited to debulking or biopsy?
  • Was radiation or chemotherapy given? If no improvement has occurred with these measures, is individual a candidate for experimental forms of radiation or chemotherapy?
  • Does the appearance of new or worsening symptoms reflect tumor growth or complications from surgery, radiation, or chemotherapy?
  • Are steroids being given to relieve symptoms from brain swelling?
  • Are anticonvulsants being given to individuals with seizures? Has individual responded well to the medications?

Regarding prognosis:

  • What type of brain cancer does individual have?
  • How malignant are the cells? Was the entire tumor removed with surgery?
  • Has individual undergone radiation and/or chemotherapy treatment? What is individual's response to surgery and other treatments?
  • Did individual's brain cancer result from metastasis of a primary tumor in a distant organ? Was the tumor of origin removed successfully? Was it possible to surgically remove the metastatic brain tumor? If not, is the metastatic cancer considered end-stage??
  • Has individual experienced complications from the cancer or from surgery or other treatments? What are they? How will these complications be treated, and how will they affect the individual?
  • Would counseling and rehabilitation assist with emotional and physical aspects of recovery in an individual who has survived a primary brain tumor?
  • Should second opinions be obtained regarding diagnosis and treatment?

Source: Medical Disability Advisor



References

Cited

"Detailed Guide: Brain / CNS Tumors in Adults." American Cancer Society. 13 May. 2009. 18 Aug. 2009 <http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?rnav=cridg&dt=3>.

Chandana, Sreenivasa R., et al. "Primary Brain Tumors in Adults." American Family Physician 77 10 (2008): 1423-1430.

Feuerstein, Michael, et al. "Work Productivity in Brain Tumor Survivors." Journal of Occupational and Environmental Medicine 48 7 (2007): 803-811.

Huff, J. Stephen. "Neoplasms, Brain." eMedicine. 1 Jul. 2009. Medscape. 7 Jan. 2014 <http://emedicine.medscape.com/article/779664-overview>.

Source: Medical Disability Advisor






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