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C&P Exam Prep: Breast Cancer (Malignant Neoplasm)

DC 7627 breast 38 CFR 4.116

DBQ Overview

Interview + Physical
Form Name
Breast_Conditions
Form Code
Breast_Conditions
Page Count
5
Examiner Type
Oncologist, Breast Surgeon, or appropriate clinician
Estimated Duration
30-45 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the current status of your breast cancer diagnosis including whether it is active or in remission, what treatments have been performed or are ongoing, the surgical history and extent of any procedures, presence of metastases, and all residual conditions resulting from the cancer or its treatment. This exam establishes the foundation for both the 100% rating during active treatment/within six months of treatment completion, and for any residual ratings thereafter.

What the examiner evaluates:

  • Whether a malignant neoplasm of the breast is currently present and whether it is active
  • Which breast(s) are affected (left, right, or bilateral)
  • Whether metastases are present and to which body systems
  • Current treatment status: active treatment, watchful waiting, or treatment completed
  • All surgical procedures performed: biopsy, wide local excision (lumpectomy), simple/total mastectomy, modified radical mastectomy, radical mastectomy, axillary or sentinel lymph node excision
  • Whether surgery resulted in significant alteration of size or form of the breast
  • Whether radiation therapy was received and to which side
  • Whether antineoplastic chemotherapy was received
  • Whether other therapeutic procedures were performed (e.g., hormonal therapy, targeted therapy, immunotherapy)
  • Dates of diagnosis, most recent treatment, and completion or anticipated completion of treatment
  • Presence of scars, disfigurement, or skin changes
  • Presence of lymphedema and its severity
  • Functional impairment including limitation of arm, shoulder, and wrist motion
  • Loss of grip strength due to cancer treatment or surgical residuals
  • Loss of sensation in the affected arm or chest wall
  • Residuals from muscle harvesting for reconstructive purposes
  • Impact on occupational functioning and daily activities
  • Whether veteran is regularly seen at a clinic for this condition
  • Any associated or secondary conditions related to breast cancer or treatment

The exam will involve a review of your medical records, a structured interview about your cancer history and current symptoms, and a physical examination. Bring all relevant medical records including oncology notes, surgical reports, pathology reports, and current treatment records. The examiner will complete the Gynecological Conditions and Disorders DBQ, which covers both the active malignancy and any chronic residuals. If your cancer is active or you are within six months of completing treatment, the primary focus will be documenting treatment status for the mandatory 100% rating. If you are more than six months post-treatment, the focus shifts to documenting residual impairments for appropriate residual ratings.

Typical duration: 30-45 minutes

Arm and Shoulder Range of Motion (ROM)

Functional limitation of the arm and shoulder on the affected side, which can result from mastectomy, axillary lymph node dissection, radiation fibrosis, or chest wall muscle harvesting for reconstruction. Rated under musculoskeletal diagnostic codes as a residual condition.

What to expect:

Goniometric measurement of shoulder flexion, abduction, internal rotation, and external rotation. May also include elbow and wrist motion. The examiner should test both active and passive ROM. If pain limits motion before the anatomical end range, that painful arc must be documented.

Key thresholds:

  • Shoulder flexion limited to 90 degrees — Corresponds to 40% rating for shoulder (DC 5201) if on major extremity, 30% if minor
  • Shoulder flexion limited to 45 degrees or less — Corresponds to higher ratings (60%+) under shoulder diagnostic codes for major extremity
  • Any painful motion — Under DeLuca factors, ROM limited by pain is rated at the point where pain begins, not the anatomical endpoint

Tips:

  • Perform your ROM test as you would on your worst day - do not push through pain to demonstrate maximum mobility
  • Inform the examiner immediately if any movement causes pain and at exactly which degree the pain begins
  • If fatigue or repetitive use makes the limitation worse, say so clearly and ask that it be documented
  • If you have had axillary lymph node dissection, you may have ongoing shoulder restriction - describe this fully
  • Ask the examiner to test both active ROM (you move the arm) and passive ROM (examiner moves the arm)

Pain considerations: Under DeLuca v. Brown, pain that limits motion is ratable at the point where pain begins. If your shoulder hurts at 60 degrees of flexion but you can force it to 90 degrees, the functional ROM should be recorded as 60 degrees. Always report exactly where pain begins during movement.

Grip Strength Assessment

Hand and forearm grip strength on the affected side, which can be diminished by nerve damage from axillary dissection, lymphedema, or radiation-induced neuropathy.

What to expect:

The examiner may use a dynamometer or manual grip testing to compare strength between your affected and unaffected hands. Numbness, tingling, or weakness in the hand or fingers should be reported.

Key thresholds:

  • Measurable grip strength loss compared to contralateral side — Supports residual rating under peripheral nerve or musculoskeletal diagnostic codes
  • Complete or near-complete loss of grip strength — May support higher residual ratings and functional impairment documentation

Tips:

  • Test on your worst day - do not over-perform to appear more capable than you are day-to-day
  • Report any numbness, tingling, burning, or shooting pain in the hand or fingers from the affected side
  • If lymphedema affects your hand or forearm, describe how it limits your ability to grasp, hold, or manipulate objects

Pain considerations: If gripping causes pain, report this clearly. Pain with use is a DeLuca factor that affects functional rating even if raw grip strength appears preserved.

Lymphedema Assessment

Presence, severity, and functional impact of lymphedema in the arm, hand, or chest wall on the side of axillary lymph node dissection or radiation. Lymphedema is a recognized chronic residual of breast cancer treatment.

What to expect:

The examiner will observe and palpate the affected arm for swelling, pitting, skin changes, and compare limb circumference to the contralateral side. They will ask about frequency of swelling, use of compression garments, and impact on daily activities.

Key thresholds:

  • Mild lymphedema (minimal swelling, responds to elevation) — Residual rating under soft tissue diagnostic codes; supports functional limitation documentation
  • Moderate to severe lymphedema (persistent, requiring compression garments, limiting arm use) — Supports higher residual ratings and significant functional impairment documentation
  • Lymphedema with recurrent infections (cellulitis) — May support additional secondary condition ratings

Tips:

  • Do not elevate or compress the arm for several days before the exam - attend with your typical baseline presentation
  • Bring or wear your compression garment to show the examiner you require it
  • Document how many days per week you experience significant swelling and what activities worsen it
  • Describe how lymphedema affects your ability to work, lift, carry, and perform household tasks

Pain considerations: Lymphedema is often painful or associated with heaviness, tightness, and aching. Describe these sensations specifically - 'my arm feels tight and heavy by midday and I cannot lift more than a light grocery bag' is more useful than 'my arm swells sometimes.'

Scar and Disfigurement Evaluation

Presence, location, size, and characteristics of surgical scars from mastectomy, lumpectomy, reconstruction, biopsy, or lymph node dissection. Also documents any disfigurement from radiation skin changes or surgical alteration of breast size or form.

What to expect:

Physical inspection of the chest, breast area, axilla, and any reconstruction sites. The examiner will note scar characteristics (adherent, non-adherent, tender, painful, keloid, hypertrophic) and document whether there is significant alteration of breast size or form.

Key thresholds:

  • Scar that is painful or unstable — Supports rating under DC 7804 (painful scar) at 10% per location
  • Scar that is adherent, not pliable, or limits underlying tissue movement — Supports higher scar ratings under DC 7805 or 7802
  • Significant alteration of breast size or form following mastectomy or wide local excision — Directly affects DBQ fields for rating category under DC 7627/7630

Tips:

  • Point out every scar including biopsy sites, port placement scars, and donor sites if muscle was harvested for reconstruction
  • Tell the examiner if any scar is painful to touch, itches, restricts movement, or becomes inflamed
  • If your scar is adherent to underlying tissue or limits your ability to raise your arm or turn, demonstrate and describe this
  • If you have had reconstruction, describe whether the form of the breast was significantly altered compared to the pre-surgical baseline

Pain considerations: Scar tenderness and pain with pressure or movement are separate ratable conditions. Do not minimize scar pain - if touching or stretching the scar causes pain, say so explicitly.

Estimate

Rating Criteria Breakdown

100% Active malignant neoplasm of the breast, OR currently underg ...

Active malignant neoplasm of the breast, OR currently undergoing surgical, radiation, antineoplastic chemotherapy, or other therapeutic procedure for breast cancer. The 100% rating continues beyond cessation of treatment. A mandatory VA examination is required six months after discontinuance of all treatment to determine the appropriate residual disability rating.

Key Symptoms

  • Active cancer diagnosis confirmed by pathology or imaging
  • Currently receiving chemotherapy (antineoplastic agents)
  • Currently receiving radiation therapy
  • Currently recovering from breast cancer surgery
  • Currently receiving hormonal therapy, targeted therapy, or immunotherapy as cancer treatment
  • Presence of metastatic disease to any body system
  • Active cancer under watchful waiting surveillance
  • Within six months of completing all cancer treatment

CFR: Under 38 CFR 4.116, DC 7627 and DC 7630: A rating of 100 percent shall continue beyond the cessation of any surgical, radiation, antineoplastic chemotherapy or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Separate 100% evaluations are assigned for both active gynecological cancer and active breast cancer per M21-1. Metastasis to a different body system is also evaluated separately.

0% Post-treatment residual rating: After the mandatory six-mont ...

Post-treatment residual rating: After the mandatory six-month post-treatment examination, the 100% rating is discontinued and replaced by ratings based on chronic residuals. Residuals are rated under the appropriate diagnostic codes within the relevant body system. Common residual ratings include: mastectomy or lumpectomy effects on breast size/form, lymphedema, shoulder/arm ROM limitation, peripheral neuropathy, scar ratings, and lymph node excision sequelae. Each residual is rated separately and combined under 38 CFR 4.25.

Key Symptoms

  • Lymphedema of the arm requiring compression garments
  • Limited shoulder or arm range of motion from surgery or radiation
  • Neuropathy or loss of sensation in the arm, hand, or chest wall
  • Loss of grip strength from nerve or muscle damage
  • Painful or disfiguring surgical scars
  • Significant alteration of breast size or form from mastectomy or lumpectomy
  • Chronic pain at surgical sites or chest wall
  • Fatigue from ongoing hormonal therapy or radiation sequelae
  • Restricted arm motion from radiation fibrosis
  • Secondary psychiatric conditions including depression or anxiety related to cancer diagnosis and treatment

CFR: Per 38 CFR 4.116 Notes under DC 7627 and DC 7630: Rate chronic residuals to include scars, lymphedema, disfigurement, and/or other impairment of function under the appropriate diagnostic code(s) within the appropriate body system. Examples include limitation of arm, shoulder, and wrist motion; loss of grip strength; loss of sensation; and residuals from harvesting of muscles for reconstructive purposes. Also evaluate under DC 7626 for scars.

How to Describe Your Symptoms

Active Cancer Status and Treatment

How to describe:

Be precise about every treatment you are receiving or have received. Name the specific chemotherapy agents if possible, the dates and frequency of radiation sessions, and all surgical procedures. Clearly state whether you are still in active treatment, on maintenance therapy, or whether treatment has been completed and when.

Worst-day example:

“I completed my last chemotherapy infusion on [date]. I am currently taking Tamoxifen daily as maintenance hormonal therapy. On my worst days during chemotherapy I was unable to get out of bed, had severe nausea for 3 days after each infusion, lost 15 pounds, and could not work for 8 months. I had radiation to my left breast - 28 sessions completed on [date] - and still have radiation dermatitis and fibrosis in the chest wall.”

What the examiner listens for:

Specific treatment modalities, dates of initiation and completion, side effects that persist after treatment ends, current medications related to cancer management, and any anticipated future procedures or surveillance schedules.

Understatements to avoid:

Do not say 'I finished chemo and I'm doing okay now.' This fails to document ongoing maintenance therapy, residual side effects, or the psychological burden of living in remission. Be thorough and specific about every symptom that persists.

Lymphedema Symptoms

How to describe:

Describe the swelling in terms of frequency, severity, what triggers it, what relieves it, and how it limits your function. Use objective measures where possible (e.g., 'my left arm is consistently 3 cm larger in circumference than my right') and describe the daily management burden.

Worst-day example:

“On my worst days my left arm swells from the hand to the elbow by early afternoon. It feels tight, heavy, and painful - like a blood pressure cuff that won't release. I cannot close my hand fully around objects. I wear a compression sleeve every day and I have to elevate my arm for at least 30 minutes in the evening. I cannot carry groceries, swing a bag, or use a keyboard for more than 20 minutes without the swelling worsening. I have had two episodes of cellulitis requiring antibiotics in the past year.”

What the examiner listens for:

Bilateral comparison of arm circumference, frequency and severity of swelling episodes, use of compression garments, history of infections, impact on grip and fine motor function, and limitation on occupational and daily activities.

Understatements to avoid:

Do not say 'I have a little swelling sometimes.' Lymphedema is a serious chronic condition. Describe it at its worst and describe what you have to do every day to manage it. If you have stopped certain activities because of lymphedema, list those activities explicitly.

Shoulder and Arm Functional Limitation

How to describe:

Connect your shoulder restriction directly to your cancer treatment - whether from axillary lymph node dissection, radiation fibrosis, mastectomy scar adhesions, or muscle harvest for reconstruction. Describe what activities you cannot do and at what point during movement pain or restriction occurs.

Worst-day example:

“Since my axillary lymph node dissection I cannot raise my left arm above shoulder height. On my worst days I cannot reach overhead to put dishes in a cabinet, wash or style my hair, or put on a shirt without significant pain starting at about 70 degrees of elevation. I had physical therapy for 6 months but my range never fully recovered. The restriction is worse in the morning and after any activity that involves using my arm.”

What the examiner listens for:

Specific degree of restriction, whether limitation is due to pain, structural restriction, or both, which activities of daily living are affected, whether the condition fluctuates (DeLuca flare-ups), and whether prior physical therapy has been completed with incomplete recovery.

Understatements to avoid:

Do not demonstrate your best possible ROM. If reaching overhead causes pain, say 'it hurts here' when pain begins - do not silently push through the pain to reach maximum range. The functional ROM is where pain begins, not the maximum anatomical endpoint.

Surgical Scars and Disfigurement

How to describe:

Identify every scar by location, describe its characteristics (raised, adherent, tender, itching, discolored), and explain how each scar affects your daily life or limits function. If the appearance of scars causes psychological distress or has affected your personal relationships, describe this as well.

Worst-day example:

“I have a 22-centimeter mastectomy scar across my left chest that is adherent and pulls when I raise my arm. It is painful to touch and aches in cold weather. I also have a 4-centimeter scar in my axilla from lymph node dissection that limits shoulder rotation. The mastectomy scar has significantly changed the appearance of my chest and I have avoided situations involving physical intimacy because of how I feel about the disfigurement.”

What the examiner listens for:

Number, location, and dimensions of scars; whether they are painful, tender to palpation, or unstable; whether they are adherent to underlying tissue; whether they limit the motion of surrounding structures; and any psychological impact from disfigurement.

Understatements to avoid:

Do not say 'I have a scar but it doesn't really bother me' if it causes any pain, restriction, or psychological distress. Each scar that is painful at rest or with movement is separately ratable. Do not minimize the functional and psychological impact of disfigurement following mastectomy.

Fatigue, Neuropathy, and Treatment Side Effects

How to describe:

Describe cancer-related fatigue, chemotherapy-induced peripheral neuropathy, cognitive effects (chemo brain), and hormonal therapy side effects with specific examples of how they limit your daily function, work capacity, and quality of life.

Worst-day example:

“I have numbness and tingling in both hands and feet from chemotherapy-induced neuropathy that never fully resolved. On my worst days I drop objects, have difficulty with buttons and fine motor tasks, and cannot feel the floor under my feet when walking. I also have severe fatigue - not like being tired, but a bone-deep exhaustion where I need 2-hour rest periods during the day just to function. My cognitive function has been affected - I forget appointments, lose words mid-sentence, and can no longer perform complex tasks at work that were routine before treatment.”

What the examiner listens for:

Specific neurological symptoms with distribution, severity of fatigue rated on a functional scale, cognitive impairment with concrete examples, and the degree to which these residuals prevent gainful employment or normal daily activities.

Understatements to avoid:

Do not assume these symptoms are outside the scope of the breast cancer exam. Chemotherapy-induced neuropathy, fatigue, and cognitive changes are compensable residuals. Describe them in detail and ask that they be documented even if the examiner does not specifically ask.

Impact on Occupational and Daily Functioning

How to describe:

The DBQ specifically asks about the impact of your breast condition on occupational functioning and daily activities. Prepare concrete examples of job tasks you can no longer perform, hours of work you have missed, and daily activities that are now limited or impossible.

Worst-day example:

“Before my diagnosis I worked full-time as a [job title] and regularly lifted 20 pounds, used a keyboard for 8 hours a day, and traveled for work. Since treatment I have been on medical leave for 14 months. I cannot lift more than 5 pounds with my left arm due to lymphedema risk, I cannot type for more than 20 minutes due to hand numbness and pain, and I cannot stand for more than 30 minutes due to fatigue and neuropathy in my feet. I rely on my spouse to carry laundry, do grocery shopping, and help me dress on my worst days.”

What the examiner listens for:

Specific occupational limitations, total work time lost, accommodations required, whether the veteran has been able to return to their prior occupation, and the degree of assistance required with activities of daily living.

Understatements to avoid:

Do not say 'I'm managing' or 'I'm doing better' in a way that minimizes your ongoing limitations. Describe your current functional capacity accurately and completely. The examiner must document impact on occupation and daily life - give them the full picture.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to receive a thorough, competent, and impartial C&P examination. The examiner must review your claims file and medical records before completing the DBQ.
  • You have the right to record your C&P examination in most states. Confirm your state's specific rules with your VSO or VA Regional Office before the exam date.
  • You have the right to request a copy of the completed DBQ examination report under the Privacy Act and Freedom of Information Act.
  • You have the right to submit a written statement challenging an inadequate, inaccurate, or incomplete C&P examination report. File this statement with your VA Regional Office promptly.
  • You have the right to request a new or supplemental C&P examination if the existing examination is found to be inadequate to rate your condition. Grounds for inadequacy include failure to test ROM, failure to address all claimed conditions, or a conclusory opinion without supporting rationale.
  • Under 38 CFR 3.303 and M21-1, the benefit of the doubt standard applies - when evidence is in approximate balance, it must be resolved in the veteran's favor.
  • Under 38 CFR 4.116, the 100% rating for active malignant neoplasm continues beyond cessation of treatment. The VA must conduct a mandatory exam six months after treatment ends before any rating reduction can occur.
  • Under 38 CFR 3.105(e), an existing disability evaluation cannot be reduced without proper notice, an opportunity to be heard, and a finding that the reduction is supported by the preponderance of medical evidence.
  • You are entitled to separate 100% evaluations for both active gynecological cancer and active breast cancer if both are present, per M21-1, Part V, Subpart iii, Chapter 8. You may also be entitled to Special Monthly Compensation (SMC) for anatomical loss of a creative organ.
  • You have the right to bring a VSO representative, accredited claims agent, or support person to your C&P examination. Confirm the facility's policy in advance.
  • You have the right to submit lay evidence - your own statements and buddy statements from family, friends, and coworkers - describing the functional impact of your condition. Lay evidence is competent evidence under 38 CFR 3.303.
  • Under DeLuca v. Brown, ROM limited by pain must be rated at the point where pain begins. You have the right to have painful ROM accurately documented, not just the maximum achievable ROM.
  • If you are denied or receive a rating you believe is incorrect, you have the right to request a Higher-Level Review, file a Supplemental Claim with new and relevant evidence, or appeal directly to the Board of Veterans Appeals.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.