IOM: Bladder Cancer, Hypothyroidism Link Veterans and Agent Orange

IOM: Bladder Cancer, Hypothyroidism Link Veterans and Agent Orange

In its 10th and final report on Veterans and Agent Orange, the Institute of Medicine (IOM) has upgraded the association between bladder cancer and hypothyroidism and exposure to toxic herbicide agents.

Veterans and Agent OrangeAdditional major findings in the 1,000-plus page report, released March 10, 2016, included Parkinsonism and Parkinson’s-like symptoms and spina bifida.

IOM announced bladder cancer and hypothyroidism were upgraded to “limited or suggestive evidence” of a link between the diseases and exposure to Agent Orange. This was a change from the Update 2012 category of “inadequate or insufficient.”

IOM also added “Parkinsonism” and “Parkinson’s-like symptoms” to the list for “limited or suggestive evidence” of an association.  In the report, the IOM Committee noted that, “…there is no rational basis for an exclusion of those with Parkinson-like symptoms from the service-related category denoted as Parkinson disease.  To exclude a claim for a condition with Parkinson-like symptoms, the onus should be on VA on a case-by-case basis to definitively establish the role of a recognized etiologic factor other than the herbicides sprayed in Vietnam.”  Parkinson’s disease was added to the Department of Veterans Affairs’ presumptive service connection list on August 31, 2010.

In a rare move, the IOM downgraded spina bifida to “inadequate or insufficient evidence to determine an association.”  The birth defect has been in the “limited or suggestive” category of association for children of all Vietnam Veterans since Update 1996.  The Committee responsible for that report used information from an Air Force Health Study that noted “more cases of spina bifida among the Operation Ranch Hand personnel than in the control group”.  In their latest report, IOM cited lack of analyses of birth defect data that found increased rates of this birth defect among children of men exposed to herbicides, including Agent Orange. Such a downgrade is rare — this is only the second time a health outcome was downgraded to a weaker category of association.

The IOM findings are not made lightly. While “biologic plausibility” is generally considered sufficient evidence of association for many scientific review boards, The Agent Orange Act of 1991 requires epidemiologic evidence (proof of disease presence in accepted, quantifiable scientific measures within a defined population) to support a finding of association.

Presumptively service-connected diseases

VA-recognized presumptive diseases and the effective date for service connection are shown in the table below. Disability compensation is not granted for a disease prior to the stated effective date shown.

Disability Effective Date
• Chloracne or other acne-form disease consistent with chloracne, and
• soft-tissue sarcoma, other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma
February 6, 1991
Note: Originally, September 25, 1985, under 38 CFR 3.311a.
Non-Hodgkin’s lymphoma (NHL) February 6, 1991
Note: Originally, August 5, 1964, under 38 CFR 3.313.
• Porphyria cutanea tarda, and
• Hodgkin’s disease
February 3, 1994
• Respiratory cancers of the lung, bronchus, larynx, or trachea, and
• multiple myeloma
June 9, 1994
• Prostate cancer, and
• acute and subacute PN
November 7, 1996
Type 2 diabetes mellitus (DM) May 8, 2001
Chronic lymphocytic leukemia (CLL) October 16, 2003
AL amyloidosis May 7, 2009
• Ischemic heart disease (IHD)
• chronic B-cell leukemia, and
• Parkinson’s disease
August 31, 2010
Early-onset peripheral neuropathy (PN) September 6, 2013
Note: The VA revised the rules for acute and subacute peripheral neuropathy (PN). The original effective date was November 7, 1996. However, the VA revised the covered disease to “early-onset PN” effective September 6, 2013.

Public Law and IOM Reports

The Agent Orange Act of 1991 (Public Law 102-4) mandated a series of biennial updates to be conducted every 2 years for 10 years from the date of the first update report.   The Veterans Educations and Benefits Expansion Act of 2001 (Public Law 107-103) mandated the update reports continue through 2014.

The Institute of Medicine released the 10th Biennial Update of the Veterans and Agent Orange (VAO) series on March 10, 2016.  In the absence of new congressional action, this will be the final update in the VAO series.

Future studies for diseases relating to herbicide exposure

The IOM recommended the VA work to answer questions about COPD, tonsil cancer, melanoma, Alzheimer disease, and paternally transmitted effects in offspring.


The Agent Orange Act of 991 (Public Law 102-4)(codified as 38USC1116)
Veterans Education and Benefits Expansion Act of 2001 (Public Law 107-103)
VA Adjudication Manual, M21-1, Part IV, Subpart ii, Chapter 1, Section H
VA Adjudication Manual, M21-1, Part IV, Subpart ii, Chapter 2, Section C
Veterans and Agent Orange: Update 2014 (2016) – Tenth Biennial Update – Institute of Medicine, The National Academies Press