Point 1. In the Jan 23 DOD Study, increased military aircrew cancer incidence was confirmed using the U.S. general population as the primary control. This DOD Study (study years 1992-2017) documented the following in DOD-only fixed wing aviators:

• Melanoma cancer: 87% higher • Thyroid cancer: 39% higher
• Prostate cancer: 16% higher
• Cancers at all sites: 24% higher

Note 1: some of the findings of the USAF/SAM May 21 Aviator Cancer Study (study years 1970-2004) concerning elevated melanoma and prostate cancer in military aviators are confirmed in the DOD Jan 23 Study
Note 2: the DOD Jan 23 Study (separately) found elevated thyroid cancer among fixed wing military aircrew. This cohort includes Army, Navy, Air Force, Marine Corps; all fixed wing aircraft, all seat positions, all grades & ranks; total force components

Note 3: the DOD Jan 23 Aviator Cancer Study did not confirm elevated aircrew non-Hodgkin lymphoma as cited in USAF/SAM May 21 Aviator Cancer Study
Note 4: the USAF/SAM May 21 Aviator Cancer Study used non-aviation service personnel as a control group

Point 2. In a first-ever cancer incidence study of military aviation support personnel (those working near/under the shadow of the aircraft wing), the following elevated cancer incidence was documented in the Jan 23 DOD Study (primary control was U.S. general population [NIH data]):

• Brain/CNS cancer: 19% higher
• Thyroid cancer: 15% higher
• Melanoma cancer: 9% higher
• Kidney/renal pelvis cancer: 9% higher • Cancers at all sites: 3% higher

Note 5: the USAF/SSAM May 21 study did not study aviation support personnel cancer incidence/death
Point 3. The DOD Jan 23 Aviator Cancer Study asserted that the death (mortality) rate for aircrew and ground crew was lower (in some cases the data were similar) when contrasted with U.S. general population. Study data make this assertion seem plausible. However, the Jan 23 DOD Study acknowledges significant cancer diagnosis/mortality shortfalls due to data non-availability/non- existence and the narrow 25-year study window, 1992 to 2017. Additionally, HIPAA mandated personnel medical data reporting and sharing protection law hides the cancer diagnosis and mortality data of tens of thousands of DOD Aviator and Ground Support Personnel who separated or retired from military service. A separate but related challenge is that the Jan 23 DOD Study did not track cancer outcomes more than 12 years after Veterans left service.

Note 6: two DOD Study findings may be open to question: aviators had 56% lower cancer mortality than US population (all sites) & aviation support personnel had 35% lower cancer mortality than US population (all sites) Note 7: the data in note 6 is colored by the issues described in Point 3. However, other factors could also be at play; specifically, these data may reflect superior detection/treatment care contrasted to the U.S. general population, so that even though they have more cancer, those cancers are better detected

Note 8: lower cancer death rates may be attributable to a cancer study condition referred to as “healthy worker effect”, or in the case of the DOD Jan 23 Study, a “Healthy Soldier Effect”. However, healthier Soldier norms (if they indeed exist), may not be universal and applicable throughout the fixed wing aviation communities of the Joint Force. The impact, if any, of a Healthy Soldier Effect on cancer outcomes in/post military life is unknown. Note 9: DOD Jan 23 Study median age at the end of follow-up for was 48 yrs. (aviators) and 41 yrs. (aviation support personnel). Median age(s) at death for aviators was 57 yrs; for support personnel, 56 yrs. This time gap of approximately 10 to 12 years between diagnosis and death may somewhat explain the DOD Study’s finding that military personnel were less prone to cancer death. The background effect at work here is the cancer latency window, that time lag from exposure to symptom onset that culminates in cancer incidence (diagnosis).

Point 4. Notwithstanding our concerns in Point 3, above, the DOD Jan 23 Aviator Cancer Study authors concede that (Point 3 factors) could/perhaps did bias the Jan 23 study findings. The thrust of the DOD Jan23 Study and our concern is the potential for a significant cancer undercount. We do not believe there has been an overcount; rather, we view the ongoing risk as undercounting. This concern initially emerged after reviewing the Air Force’s May 21 Cancer Study. We believe that unless major gaps in military member cancer tracking and relevant data collection are addressed, significant cancer undercounting is likely to persist in any future DOD and Veteran cancer incidence studies accomplished at scale.

A product of the RRVA Aviation Medical Issues Committee 6 APR 23 questions email: medical@river-rats.org