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Veterans and Agent Orange: Update 2014 (2016)

Chapter: Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers

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Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×

Appendix C

Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers

In response to a request from the Department of Veterans Affairs, the committee responsible for Update 2006 prepared Table C-1 to demonstrate how conclusions provided for the full range of cancer types and to clarify into which groupings any specific cancer diagnosis falls. The committee for Update 2010 reframed its overview of lymphohematopoietic neoplasms according to the World Health Organization (WHO) classification system (WHO, 2008), which partitions these disorders first according to the lymphoid or myeloid lineage of the transformed cells rather than as lymphomas or leukemias; this emphasizes the close etiologic relationship of chronic lymphocytic leukemia and hairy-cell leukemia with Hodgkin and non-Hodgkin lymphomas and with the neoplasm multiple myeloma and its related condition AL amyloidosis.

The major portion of evidence compiled for review in the Veterans and Agent Orange (VAO) series comes from cohort studies, primarily of mortality but also some of incidence. Other data have been generated by case-control studies, which follow the only design amenable to studying very infrequent or very specific health outcomes. How researchers are able to group, analyze, and report their findings is influenced by the distribution of cases that they observe, so the data that VAO committees have had available for review reflect mortality experience at a level of specificity concordant with statistical analysis.

The International Classification of Diseases (ICD) system is used by physicians and researchers around the world to group related diseases and procedures so that morbidity and mortality information can be classified for statistical purposes in a standard form that is amenable to data storage and retrieval. It is a comprehensive hierarchic system that permits great detail but that can be collapsed into broad categories. Codes mentioned in VAO reports are stated in terms

Page 1068 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×

TABLE C-1 Mapping of Groupings of Malignant Neoplasms That Are the Subjects of Conclusions in the Veterans and Agent Orange Series with ICD-9 Codes

NIOSH Category for Cause of Death NIOSH Groupings of Cancer Sites “VAO Characterization of Grouping”a
Subsites
ICD-9 Codes
Major Minor      
02   Buccal cavity and pharynx “Oral, nasal, and pharyngeal”  
004 Lip   140
005 Tongue   141
006 Other parts of buccal cavity    
Salivary glands 142
Floor of mouth 144
Gum and other mouth 143, 145
007 Pharynx    
Oropharynx 146
Tonsil 146.0–146.2
Nasopharynx 147
Hypopharynx 148
Other buccal cavity and pharynx 149
  (160 = nasal below)
03   Digestive organs and peritoneum    
008 Esophagus “Esophagus” 150
009 Stomach “Stomach” 151
010 Intestine except rectum “Colorectal”  
Small intestine 152
Colon (large intestine) 153
011 Rectum   154
012 Biliary passages, liver, and gall bladder “Hepatobiliary”  
Liver and intrahepatic bile ducts 155
Gallbladder and extrahepatic bile ducts 156
013 Pancreas   157
Page 1069 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
014

Retroperitoneum and other and unspecified digestive organs

  158–159
04   Respiratory system “Respiratory”  
015 Larynx “Larynx” 161
016 Trachea, bronchus, and lung “Lung” 162
Trachea 162.0 (there is no ICD 162.1)
Lung and bronchus 162.2–162.9
017 Pleura   163
018 Other respiratory    

Nasal cavity, middle ear, and accessory sinuses

(160, above with oral and pharyngeal)
Thymus, heart, and mediastinum

164 (164.0, below with endocrine; 164.1, below with soft tissue sarcoma)

Other respiratory, unspecified 165
  (discontinuity with ICD codes)
05 019 Breast (male and female) “Breast” 174, 175
06   Female genital organs “Female reproductive”  
020 Cervix uteri   180
021 Other unspecified parts of uterus   179, 181, 182
Uterus, parts unspecified 179
Placenta 181
Body of uterus 182
022 Ovary, fallopian tube, and broad ligament   183
Ovary 183.0 (there is no ICD 183.1)
Fallopian tube and other uterine adnexa 183.2–183.9
023 Other female genital organs   184
07   Male genital system   185, 186
024 Prostate “Prostate” 185
025 Testis “Testicular” 186
Penis and other male genital organs [for NIOSH in minor group 036] 187
Page 1070 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
NIOSH Category for Cause of Death NIOSH Groupings of Cancer Sites “VAO Characterization of Grouping”a
Subsites
ICD-9 Codes
Major Minor      
08   Urinary system    
026 Kidney (including renal pelvis and ureter) “Renal” 189.0–189.2
027 Bladder and other urinary organs “Urinary bladder” 188, 189.3–189.9
Bladder 188

Urethra, paraurethral glands, other and unspecified urinary

189.3–189.9
        (discontinuity with ICD codes)
09   Other and unspecified sites    
028

Bone (“and articular cartilage” in ICD nomenclature)

“Bone and joint” 170
029 Melanoma “Melanoma” 172
030 Other malignant skin neoplasm “Non-melanoma skin” 173
031 Mesothelioma  

No codes (new minor code, above with lung)

032

Connective (“and other soft” in ICD nomenclature) tissue

“Soft-tissue sarcomas” 171
(heart) (164.1)
033 Brain and other parts of nervous system “Brain” 191–192

(ICD “soft tissue” includes peripheral nerves and autonomic nervous system)

034 Eye   190
035 Thyroid   193
(thymus) 164.0
036 Other and unspecified sites Other endocrine cancers 194
Other and ill-defined sites 195
Page 1071 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
     

Stated or assumed to be secondary of specified sites

196–198
      Site unspecified 199
10   Lymphatic and hematopoietic tissue    
Lymphoma
037 Hodgkin disease   201
038 Non-Hodgkin lymphoma   200, 202 (excluding 202.4), 273.3
039 Multiple myeloma   203 (excluding 203.1)
040 Leukemia and aleukemia

“Leukemias (other than chronic B-cell leukemias)”

204–208
Lymphocytic

primary grouping now with other neoplasms of lymphocytic origin, lymphomas and multiple myeloma

 
Acute lymphocytic 204.0

“Chronic lymphocytic (including hairy cell leukemia)”

204.1
Other lymphocytic 202.4; 204.2–204.9
Myeloid (granulocytic)    
Acute myeloid  
Acute 205.0
Acute erythremia and erythroleukemia 207.0
Megakaryocytic leukemia 207.2
Chronic myeloid 205.1
Other myeloid 205.2–205.3, 205.8–205.9
Monocytic    
Acute monocytic 206.0
Chronic monocytic 206.1
Other monocytic 206.2–206.9
Other leukemias    
Other acute 208.0
Other chronic 207.1, 208.1

Aleukemic, subleukemia and “not otherwise specified”

203.1, 207.2, 207.8, 208.2–208.9
 

aBoldface cancer (sub)site: most comprehensive grouping for which a conclusion has been drawn.

Page 1072 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×

of ICD, Revision 9 (ICD-9). ICD-7, ICD-8, and ICD-9 were in effect for deaths that occurred in 1960–1967, 1968–1978, and 1979–1998, respectively; the differences among them are fairly subtle. Although ICD-10, which went into effect for coding causes of deaths that occurred from 1999 on, appears radically different from the earlier versions, it corresponds in large part to basically the same disease entities (see Table C-2). Most published epidemiologic studies considered in the VAO series have been related to health outcomes that occurred and were encoded before ICD-10 went into effect.

Since 1983, the National Institute for Occupational Safety and Health (NIOSH) has maintained software for generating standardized expectations, as derived from US mortality data assembled by the National Center for Health Statistics, for ICD-encoded mortality datasets. An article by Robinson et al. (2006) discusses revisions to that standard software to incorporate deaths coded according to ICD-10 and includes conversions and equivalences among ICD-7, ICD-8, ICD-9, and ICD-10 for 119 exhaustive categories of cause of death. Codes for malignant neoplasms span the ICD-9 range 140.0–208.9, NIOSH’s major categories 02–10, or NIOSH’s more specific minor categories 004–040.

The NIOSH death codes for neoplasms provide a comprehensive scaffolding for organizing the committee’s reviews and conclusions by cancer type, which is somewhat simpler than ICD classifications but maps completely to the ICD system as it has evolved. Because the NIOSH system has been used to mediate analysis of many sets of cohort data, its groupings correspond quite closely to the published research findings available for review by VAO committees. In general cohort studies, one is unlikely to encounter results on more specific groupings than NIOSH’s minor categories.

As discussed in Chapter 2, the VAO committees have not framed its conclusions strictly in terms of ICD codes, but the ICD system has been a valuable tool for the work of VAO committees. There can be coding errors on hospital records or death certificates, but when researchers present their results labeled with ICD codes, there can be little ambiguity about what they intended. When their most definitive indication is something like “respiratory cancers,” however, there can be uncertainty about where the evidence should be considered. In such cases, the committee has done its best to follow the hierarchy laid out in Table C-1.

As indicated above, many of the studies reviewed by the committee use or were written up at a time when ICD-9 was in place. Accordingly, ICD references in this report use that scheme. ICD-10 began to be implemented in the United States in 1999. It differs from ICD-9 in level of detail (about 8,000 categories versus about 5,000 in ICD-9) and nomenclature (alphanumeric versus the numeric codes of ICD-9); additions and modifications were also made with regard to some coding rules and the rules for selecting an underlying cause of death (Anderson et al., 2001). Table C-2 lists the ICD-9 and ICD-10 codes for the various forms of malignant neoplasm addressed in this report. In situ neoplasms, benign neoplasms, neoplasms of uncertain behavior, and neoplasms of unspecified behavior have separate codes in both schemes.

Page 1073 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×

TABLE C-2 Surveillance, Epidemiology, and End Results (SEER) Program Malignant Neoplasm Site Groupings for ICD-9 and ICD-10

Cancer Site ICD-9 Codes ICD-10 Codes
Buccal cavity and pharynx    

Lip

140.0–140.9

C00.0–C00.9

Tongue

141.0–141.9

C01, C02.1–C02.9

Salivary glands

142.0–142.9

C07, C08.0–C08.9

Floor of mouth

144.0–144.9

C04.0–C04.9

Gum and other mouth

143.0–143.9, 145.0–145.6, 145.8–145.9

C03.0–C03.9, C05.0–C05.9, C06.0–C06.9

Nasopharynx

147.0–147.9

C11.1–C11.9

Tonsil

146.0–146.2

C09.0–C09.9

Oropharynx

146.3–146.9

C10.1–C10.9

Hypopharynx

148.0–148.9

C12, C13.0–C13.9

Other buccal cavity and pharynx

149.0–149.9

C14.0–C14.9

Digestive system    

Esophagus

150.0–150.9

C15.0–C15.9

Stomach

151.0–151.9

C16.0–C16.9

Small intestine

152.0–152.9

C17.0–C17.9

Colon excluding rectum

153.0–153.9, 159.0

C18.0–C18.9, C26.0

Rectum and rectosigmoid junction

154.0–154.1

C19, C20

Anus, anal canal, and anorectum

154.2–154.3, 154.8

C21.0–C21.9

Liver and intrahepatic bile duct Liver

155.0,155.2

C22.0, C22.2–C22.4, C22.7–C22.9

Intrahepatic bile duct

155.1

C22.1

Gallbladder

156.0

C23

Other biliary

156.1–156.9

C24.0–C24.9

Pancreas

157.0–157.9

C25.0–C25.9

Retroperitoneum

158.0

C48.0

Peritoneum, omentum, and mesentery

158.8–158.9

C48.1–C48.2

Other digestive organs

159.8–159.9

C26.8–26.9, C48.8

Respiratory system    

Nasal cavity, middle ear, and accessory sinuses

160.0–160.9

C30.0, C30.1, C31.0–C31.9

Larynx

161.0–161.9

C32.0–C32.9

Lung and bronchus

162.2–162.9

C34.0–C34.9

Pleura

163.0–163.9

C38.4

Trachea, mediastinum, and other respiratory organs

162.0, 164.2–165.9

C33, C38.1–C38.3, C38.8, C39

Bones and joints

170.0–170.9

C40.0–C40.9, C41.0–C41.9

Soft tissue (including heart)

171.0–171.9, 164.1

C38.0, C47.0–C47.9, C49.0–C49.9

Page 1074 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Cancer Site ICD-9 Codes ICD-10 Codes
Skin    

Malignant melanomas

172.0–172.9

C43.0–C43.9

Other malignant skin neoplasms

173.0–173.9

C44.0–C44.9

Breast (male and female)

174.0–174.9, 175

C50.0–C50.9

Female genital system

Cervix

180.0–180.9

C53.0–C53.9

Corpus

182.0–182.1, 182.8

C54.0–C54.9

Uterus, not otherwise specified

179

C55

Ovary

183.0

C56.0–C56.9

Vagina

184.0

C52

Vulva

184.1–184.4

C51.0–C51.9

Other female genital organs

181, 183.2–183.9, 184.8, 184.9

C57.0–C57.9, C58

Male genital system

Prostate

185

C61

Testis

186.0–186.9

C62.0–C62.9

Penis

187.1–187.4

C60.0–C60.9

Other male genital organs

187.5–187.9

C63.0–C63.9

Urinary system

Urinary bladder

188.0–188.9

C67.0–C67.9

Kidney and renal pelvis

189.0, 189.1

C64.0–C64.9, C65.0–C65.9

Ureter

189.2

C66.0–C66.9

Other urinary organs

189.3–189.4, 189.8–189.9

C68.0–C68.9

Eye and orbit

190.0–190.9

C69.0–C69.9

Brain and other nervous system

Brain

191.0–191.9

C71.0–C71.9

Meninges

192.1

C70.0–C70.9

Other nervous systema

192.0, 192.2–192.9

C72.0–C72.9

Endocrine system

Thyroid

193

C73

Other endocrine (including thymus)

164.0, 194.0–194.9

C37, C74.00–C74.92, C75.0–C75.9

Lymphomas

Hodgkin’s disease

201.0–201.9

C81.0–81.9

Non-Hodgkin’s lymphomas

200.0–200.8, 202.0–202.2, 202.8–202.9

C82.0–C82.9, C83.0–C83.9, C84.0–C84.5, C85.0–C85.9, C96.3

Multiple myeloma

203.0, 238.6

C90.0, C90.2

Page 1075 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Cancer Site ICD-9 Codes ICD-10 Codes
Leukemias    

Lymphocytic

   

Acute lymphocytic

204.0

C91.0

Chronic lymphocytic

204.1

C91.1

Other lymphocytic

202.4, 204.2–204.9

C91.2-C91.4, C91.7, C91.9

Myeloid (granulocytic)

Acute myeloid

205.0, 207.0, 207.2

C92.0, C92.4–C92.5, C94.0, C94.2

Chronic myeloid

205.1

C92.1

Other myeloid

205.2–205.3, 205.8–205.9

C92.2–C92.3, C92.7, C92.9

Monocytic

Acute monocytic

206.0

C93.0

Chronic monocytic

206.1

C93.1

Other monocytic

206.2–206.9

C93.2, C93.7, C93.9

Other leukemias

Other acute

208.0

C94.4, C94.5, C95.0

Other chronic

207.1, 208.1

C94.1, C95.1

Aleukemic, subleukemic and “not otherwise specified”

203.1, 207.2, 207.8, 208.2–208.9

C90.1, C91.5, C94.3, C94.7, C95.2, C95.7, C95.9

Miscellaneous malignant neoplasms

159.1, 195.0–195.8, 196.0–196.9, 199.0–199.1, 202.3, 202.5–202.6, 203.8

C26.1, C76.0–C76.8, C77.0–C77.9, C78.0–C78.8, C79.0–C79.8, C80, C88.0–C88.9, C96.0–C96.2, C96.7, C96.9, C97

aCancers of the peripheral nerves and the autonomic nervous system are classified as “soft tissue” in ICD.

SOURCE: Adapted from Ries et al., 2003, Table A-4.

REFERENCES

The Appendix C references can be found in the References chapter.

Page 1076 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×

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Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
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Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1068
Page 1069 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1069
Page 1070 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1070
Page 1071 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1071
Page 1072 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1072
Page 1073 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1073
Page 1074 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1074
Page 1075 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
Page 1075
Page 1076 Cite
Suggested Citation:"Appendix C: Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to National Institute for Occupational Safety and Health Cause-of-Death Codes and International Classification of Diseases Codes for Cancers." National Academies of Sciences, Engineering, and Medicine. 2016. Veterans and Agent Orange: Update 2014. Washington, DC: The National Academies Press. doi: 10.17226/21845.
×
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From 1962 to 1971, the US military sprayed herbicides over Vietnam to strip the thick jungle canopy that could conceal opposition forces, to destroy crops that those forces might depend on, and to clear tall grasses and bushes from the perimeters of US base camps and outlying fire-support bases. Mixtures of 2,4-dichlorophenoxyacetic acid (2,4-D), 2,4,5-trichlorophenoxyacetic acid (2,4,5-T), picloram, and cacodylic acid made up the bulk of the herbicides sprayed. The main chemical mixture sprayed was Agent Orange, a 50:50 mixture of 2,4-D and 2,4,5-T. At the time of the spraying, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), the most toxic form of dioxin, was an unintended contaminant generated during the production of 2,4,5-T and so was present in Agent Orange and some other formulations sprayed in Vietnam.

Because of complaints from returning Vietnam veterans about their own health and that of their children combined with emerging toxicologic evidence of adverse effects of phenoxy herbicides and TCDD, the National Academy of Sciences was asked to perform a comprehensive evaluation of scientific and medical information regarding the health effects of exposure to Agent Orange, other herbicides used in Vietnam, and the various components of those herbicides, including TCDD. Updated evaluations were conducted every two years to review newly available literature and draw conclusions from the overall evidence. Veterans and Agent Orange: Update 2014 is a cumulative report of the series thus far.

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