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incapacitation. They are:
a) The recurrence rate per year for any stage of tumour X (as a percentage)
b) The frequency of metastatic disease in a particular organ (as a percentage)
c) The risk that a metastasis in a particular organ will cause incapacitation (as a percentage)
A formula can now be derived to calculate the total risk of a particular metastasis causing incapacitation
in any year after completion of primary treatment. The example below is for brain metastases.
(Tumour X recurrence rate) × (Incidence of brain metastases) × (Risk of brain metastasis causing
incapacitation) = risk of incapacitation from brain metastases in tumour X
ICAO Preliminary Unedited Version — October 2008 III-15-7
Using the figures that we have obtained, numbers can be put to this formula. The tumour recurrence rates
per year are from Figure 2.
Year 1 / Stage 1 : 1/20 (5%) × 1/10 (10%) × 1/1 (100%) = 1/200 = 0.5% risk of incapacitation
Year 1 / Stage 2 : 3/20 (15%) × 1/10 (10%) × 1/1 (100%) = 3/200 = 1.5% risk of incapacitation
Year 1 / Stage 3 : 3/10 (30%) × 1/10 (10%) × 1/1 (100%) = 3/100 = 3.0% risk of incapacitation
In the first year, therefore, the average risk of incapacitation due to brain metastases ranges from 0.5 per
cent to 3.0 per cent, depending n the staging of the tumour. This would allow a range of certification as
shown in Table 5.
YEAR 1 – BRAIN METASTASES
Year 1 – brain metastases
Stage Incapacitation risk Professional certification Private certification
1 0.5% Multi-crew restriction Unrestricted
2 1.5% None Restricted
3 3.0% None Restricted
Table 5.– Range of certification possible in first year after completion of treatment
By year 5 the prognosis has improved and the incapacitation risks have decreased. Again the tumour
recurrence rates are taken from Figure 2.
Year 5 / Stage 1 : 1/100 (1%) × 1/10 (10%) × 1/1 (100%) = 1/1000 = 0.1% risk of incapacitation
Year 5 / Stage 2 : 1/20 (5%) × 1/10 (10%) × 1/1 (100%) = 1/200 = 0.5% risk of incapacitation
Year 5 / Stage 3 : 1/5 (20%) × 1/10 (10%) × 1/1 (100%) = 1/50 = 2% risk of incapacitation
In the fifth year the risk of incapacitation has now fallen to between 0·1 and 2%. The range of acceptable
certification has also increased, as shown in Table 6:
YEAR 5 – BRAIN METASTASES
Year 5 – brain metastases
Stage Incapacitation risk Professional
certification
Private
certification
1 0.1% Unrestricted Unrestricted
2 0.5% Multi-crew
restriction
Unrestricted
3 2.0% None Restricted
Table 6.– Range of certification possible in fifth year after completion of treatment
Other types of recurrence are possible (and indeed more likely) than brain metastases, but because of the
“incapacitation weighting” given to each anatomical recurrence, brain lesions contribute most to the total
risk of incapacitation. The combined risks of several sites of recurrence may need to be taken into
account.
ICAO Preliminary Unedited Version — October 2008 III-15-8
Presenting the total risk of incapacitation
A table can be used to show the type of certification possible depending on time since completion of
primary treatment and stage (Table 7):
Year since completion of primary treatment
Stage
1 2 3 4 5
1 0.5%
(5%×10%×100%)
(1/20×1/10×1/1×100%)
0.2%
(2%×10%×100%)
0.1%
(1%×10%×100%)
0.1%
(1%×10%×100%)
0.1%
(1%×10%×100%)
2 1.5%
(15%×10%×100%)
1.2%
(12%×10%×100%)
0.9%
(9%×10%×100%)
0.7%
(7%×10%×100%)
0.5%
(5%×10%×100%)
Table 7.– Certification possibilities according to stage and time since completion of treatment
This can be displayed graphically in a chart as shown in Figure 3:
Stage Years since completion of treatment
1 2 3 4 5
1
2
Unrestricted Class 1
Class 1 with multi-crew restriction or unrestricted Class 2
No Class 1 – restricted Class 2
Figure 3.– Chart indicating certification possibilities according
to stage and time since completion of treatment
Using certification assessment charts
It must be emphasized that charts are only for guidance. Flight crew with tumours that have a number of
additional good prognostic factors may be returned to flying earlier than the “average” example
demonstrated by the chart. Conversely, if adverse prognostic factors are present, further delay may be
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Manual of Civil Aviation Medicine 2(112)
