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haemoglobin, and this should serve as a reminder both to the pilot and the medical examiner that there are
potential risks when entering a hypoxic environment.
An unfit assessment applies both to curative chemotherapy, for example, treatment of disseminated
lymphoma, and to adjuvant chemotherapy, for example when given to prevent the possible recurrence of
colorectal cancer following surgical excision. The latter treatment may extend over a prolonged period of
time, and there may well be a conflict between the medical advice to have the adjuvant treatment and the
pilot’s desire to regain medical certification to fly.
The only exception to an unfit assessment during adjuvant treatment for malignancy is endocrine therapy.
Certain adjuvant hormone and anti-hormone treatments following (for example) breast or prostate
cancer treatment may be acceptable if there are no side effects.
Stem cell transplantation
It is possible to return to flying after stem cell transplantation if there is sustained remission.
CERTIFICATION AFTER PRIMARY TREATMENT
Defining acceptable risk
In this discussion the assumption is made that the primary treatment, be it surgery, radiotherapy,
chemotherapy or a combination of these, has removed all signs of tumour “X” when measured clinically
or by investigation. The risk to flight safety is now the possibility that local or metastatic recurrence will
cause sudden or insidious incapacitation whilst the pilot is flying.
The concept of “acceptable risk” or “the one per cent rule” has been discussed elsewhere in this manual.
Much work in aviation cardiology has defined a risk of incapacitation of one per cent per year or less to
be acceptable for two-crew professional operations as well as unrestricted private flying. This can also be
applied to certification after treatment for malignant disease. One difference between cardiology (a topic
that is well-suited to the application of objective risk assessment) and oncology is that with the former,
once the risk has been defined and certification achieved, the pathological condition is not likely to go
away. After treatment of malignancy, however, the prognosis improves with recurrence-free time after the
original episode. Thus to consider the full range of certification possibilities, from no certificate to
unrestricted Class 1, and including Class 2 certification for private flying, acceptable incapacitation risk
levels have to be defined.
ICAO Preliminary Unedited Version — October 2008 III-15-3
In this discussion, the following annual incapacitation risks will be used to define the appropriate
certification. It should be noted that the exact levels of acceptable risk for restricted Class 2 certification
(restricted private flying1) have not been defined. For single-crew professional flying a figure of 0.1 per
cent has been empirically quoted and is a reasonable basis, given that it is an order of magnitude less than
the maximal acceptable multi-crew figure and is the approximate cardiovascular risk of men in their 40s
(see Table 2).
For the purpose of these calculations, a five per cent annual incapacitation risk has been taken as the
upper limit for restricted private flying.
Incapacitation risk per year Acceptable level of certification Licence
Less than 0.1 per cent Any Any
Between 0.1 and 1 per cent Class 1 restricted
Class 2 unrestricted
Multi-crew only
Private
Greater than 1 per cent No Class 1
Possibly Class 2 restricted
No professional
Private with restriction
Table 2.— Certification possibilities according to acceptable risks of incapacitation
Thus if an incapacitation rate per year can be derived for ``tumour X`` at any particular time following its
original treatment, then an acceptable level of certification for that pilot, at that time, can be calculated
from the table above.
Following “successful” primary treatment, the risk that tumour X will cause an insidious or sudden
incapacitation depends on two factors. The first is the actual risk of recurrence, which will depend on the
pathological stage of the tumour or its TNM classification2. The second is the site of that recurrence, and
this will depend on the primary tumour type. These two factors will now be discussed individually, again
in relation to a hypothetical tumour X.
Defining the risk of recurrence
The annual recurrence rate of tumour X can be calculated from survival curves. Ideally these should be
“recurrence free” survival curves, but those are often not available, and thus simple survival data will
need to be used. However, unless it is possible to cure many patients once their tumour has recurred (not a
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Manual of Civil Aviation Medicine 2(110)
