Citation Nr: 1510226	
Decision Date: 03/11/15    Archive Date: 03/24/15

DOCKET NO.  09-34 890	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Columbia, South Carolina


THE ISSUE

Entitlement to service connection for residuals of squamous cell carcinoma at the base of the tongue/oral pharynx, to include as a result of exposure to ionizing radiation.


ATTORNEY FOR THE BOARD

Elizabeth Jalley, Counsel


INTRODUCTION

The Veteran served on active duty from June 1959 to January 1964 and from August 1964 to December 1965.

This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson Mississippi.

Jurisdiction of the claims file has been transferred to the RO in Columbia, South Carolina.

In May 2011, the Board remanded this case for additional development, and the case has been returned for further appellate review.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c).  38 U.S.C.A. § 7107(a)(2) (West 2014).


FINDING OF FACT

Squamous cell carcinoma at the base of the tongue/oral pharynx was not manifested during the Veteran's active duty service or for many years thereafter, nor is it otherwise related to the Veteran's active duty service, to include the Veteran's exposure to ionizing radiation during service.


CONCLUSION OF LAW

Squamous cell carcinoma at the base of the tongue/oral pharynx was not incurred in or aggravated by the Veteran's active duty service, nor may it be presumed to be incurred in such service.  38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.311 (2014).


REASONS AND BASES FOR FINDING AND CONCLUSION

I.  Veterans Claims Assistance Act

The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims.  VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2014)).  In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA.  See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2014)). 

The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing.  Quartuccio v. Principi, 16 Vet. App. 183 (2002).  The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability.  Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction.  Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004).  The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant.  See Dingess, supra; Pelegrini, supra.

The Board finds that the notification requirements of VCAA have been satisfied in this case.  In this regard, the Board notes evidentiary development letters dated in February 2006 and March 2006 in which the RO advised the appellant of the evidence needed to substantiate his service connection claim.  These letters were sent prior to the initial adjudication of the Veteran's claim in September 2007.  The appellant was advised in these letters of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA.  Letters dated in March 2006 and May 2006 further advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claim.

The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case.  38 U.S.C.A. §§ 5103 and 5103A.  Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issue on appeal has been obtained and associated with the claims folder.  In particular, the Board notes that the RO obtained the Veteran's service treatment records and identified private medical records.  As will be discussed in more detail below, VA has also obtained an estimate of the Veteran's radiation dose exposure and a June 2014 opinion from the Director, Compensation Service.  

The evidence of record provides sufficient information to adequately evaluate the claim.  Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran.  38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006).

II.  Service Connection

The Veteran has claimed entitlement to service connection for residuals of squamous cell carcinoma at the base of the tongue/oral pharynx.  The Veteran notes that he developed his cancer in 1997, which was more than three decades following his separation from service.  He contends, however, that this disability resulted from his exposure to ionizing radiation during service.  

In a February 2006 statement, the Veteran reported that he was exposed to radiation while stationed at Castle Air Force Base and Mather Air Force Base.  He reported that "[t]his exposure was due to being around atomic bombs during tours at these bases."  He reported having spent more than five and a half years at these bases.  On a February 2006 "Radiation Risk Activity Information Sheet," the Veteran reported that he was around atomic bombs while in the Air Police Field.  

In a June 2006 statement, he reported that some of his duties in Air Force Police "involved being around and guarding atomic bombs in the munitions area and in the airplane areas."

In an October 2014 statement, the Veteran reported that he "was exposed to atomic weapons and did spend time in the atomic weapons bunker storage area and also was exposed to atomic weapons on the flight line around the B-52's."  

Claims based upon exposure to ionizing radiation are governed by separate regulations and each provides a separate distinct basis for establishing service connection.  See 38 C.F.R. §§ 3.309, 3.311.

First, there are diseases that are presumptively service connected in radiation-exposed Veterans under 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d).  Second, service connection may be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a radiogenic disease.  Third, direct service connection can be established under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions.  See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994).  Under Combee, VA must not only determine whether a Veteran had a disability recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether the disability was otherwise the result of active service.  In other words, the fact that the requirements of a presumptive regulation are not met does not in and of itself preclude a claimant from establishing service connection by way of proof of actual direct causation.  38 C.F.R. § 3.309(d)

A disease associated with exposure to radiation listed in 38 C.F.R. § 3.309(d) will be considered to have been incurred in service by a radiation-exposed Veteran under the circumstances outlined in that section.  Specifically, if a Veteran, while on active duty, active duty for training, or inactive duty training, participated in a "radiation-risk activity," then the diseases listed under 38 C.F.R. § 3.309(d) shall be service-connected, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 are also satisfied.  The listed diseases include (i) leukemia (other than chronic lymphocytic leukemia); (ii) cancer of the thyroid; (iii) cancer of the breast; (iv) cancer of the pharynx; (v) cancer of the esophagus; (vi) cancer of the stomach; (vii) cancer of the small intestine; (viii) cancer of the pancreas; (ix) multiple myeloma; (x) lymphomas (except Hodgkin's disease); (xi) cancer of the bile ducts; (xii) cancer of the gall bladder; (xiii) primary liver cancer (except if cirrhosis or hepatitis B is indicated); (xiv) cancer of the salivary gland; (xv) cancer of the urinary tract; (xvi) bronchiolo-alveolar carcinoma; (xvii) cancer of the bone; (xviii) cancer of the brain; (xix) cancer of the colon; (xx) cancer of the lung; and (xxi) cancer of the ovary.  38 C.F.R. § 3.309(d).  

The term "radiation-exposed Veteran" includes a Veteran who while serving on active duty participated in a "radiation-risk activity."  38 U.S.C.A. § 1112; 38 C.F.R. § 3.309(d).  A "radiation-risk activity" is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan, or Nagasaki, Japan, by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945, through July 1, 1946.  38 C.F.R. § 3.309(d)(3)(ii).  Other "radiation-risk activities" include certain circumstances in which the service member was present for at least 250 days before February 1, 1992, on the grounds of a gaseous diffusion plant located in Paducah, Kentucky, Portsmouth, Ohio, or the area identified as K25 at Oak Ridge, Tennessee; or served before January 1, 1974, on Amchitka Island, Alaska.  Id.  

In this case, it is not shown that the Veteran participated in a radiation risk activity as defined in 38 C.F.R. § 3.309(d).  While the Veteran has asserted, such as in his September 2009 substantive appeal, that he engaged in "radiation-risk activity" during service, the activities that he considers to be "radiation-risk activities" do not satisfy the definition of "radiation-risk activities" that appears in 38 C.F.R. § 3.309(d).  The Veteran's statements, including his February 2006 written explanation of his contended radiation exposure, do not assert that he participated in any specified "radiation risk activity" as defined by 38 C.F.R. § 3.309(d)(3)(ii).  As such, the provisions of 38 C.F.R. § 3.309(d) do not apply in this case.

Service connection may also be considered based on exposure to ionizing radiation under the provisions of 38 C.F.R. § 3.311.  To consider service connection under Section 3.311, the evidence must show the following: (1) the Veteran was exposed to ionizing radiation in service; (2) he subsequently developed a radiogenic disease; and (3) such disease first became manifest within a period specified by the regulations.  38 U.S.C.A. § 501; 38 C.F.R. § 3.311(b).  For cancer, the disease must have manifested five years or more after exposure.  38 C.F.R. § 3.311(b)(5).  If these three requirements are met, the claim must be referred to the Under Secretary for Benefits for further consideration.  

This section does not provide presumptive service connection for radiogenic diseases, but only outlines a procedure to be followed for adjudication purposes.  Medical opinions are ultimately the criteria upon which service connection rests under this regulation.

For the purposes of 38 C.F.R. § 3.311, radiogenic disease means a disease that may be induced by ionizing radiation and shall include the following:  All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; cancer of the thyroid, breast, lung, bone, liver, skin, esophagus, stomach, colon, pancreas, kidney, urinary bladder, salivary gland, and ovary; multiple myeloma, posterior subcapsular cataracts, non-malignant thyroid nodular disease; parathyroid adenoma; tumors of the brain and central nervous system; cancer of the rectum, lymphomas other than Hodgkin's disease, prostate cancer; and any other cancer.  38 C.F.R. § 3.311(b)(2) .

Squamous cell carcinoma at the base of the tongue/oral pharynx is included in the "any other cancer" categorization and is thus considered a  "radiogenic" disease under 38 C.F.R. § 3.311(b).  Again, this regulation does not create a presumption of service connection, but merely accords the claimant special processing of the claim.  Such processing "still requires a case-by-case determination of service connection for each claim based on one of the listed diseases."  See Ramey v. Brown, 120 F.3d 1239, 1245 (Fed. Cir. 1997)

The Veteran, including in his February 2006, June 2006, and October 2014 written statements on this subject, has asserted that his in-service responsibilities included guarding munitions areas containing atomic bombs while working in the Air Police Field and working near atomic weapons on the flight line.  

In terms of in-service ionizing radiation exposure, the Veteran's service personnel records contain a DD Form 1141, "Record of Exposure to Ionizing Radiation."  This record notes an inclusive date in May 1962, a "method of measure" of "CP-95," a dose and an accumulative total dose of "0/R," and a DT-60 reading of "X."  The Veteran's DD Form 214 reflects that the Veteran's military occupational specialty (MOS) was "Air Policeman."  The post-service evidence reflects a diagnosis of squamous cell carcinoma, aggressive basaloid variant (base of tongue) in May 1997.  

The record contains an August 2007 memorandum from the Department of the Air Force, Deputy Chief, Radiation Protection Division, USAF Radioisotope Committee Secretariat, Air Force Medical Operations Agency, Office of the Surgeon General.  It notes that it had "queried the occupational radiation monitoring records in the USAF Master Radiation Registry (MRER) for [the Veteran].  We found no external or internal exposure data on this individual."  It notes that "there appears to have been cases where early records, especially the DD Form 1141, were maintained in the individual's military medical record or by the local unit and were not forwarded for inclusion in the central repository."  (In the case at hand, the Veteran's DD Form 1141 was located in the Veteran's service treatment records and was described above.)  

Following the Board's May 2011 remand, the RO contacted the Defense Threat Reduction Agency (DTRA) in June 2013 and provided information relevant to obtaining a radiation dose estimate.  In a July 2013 response, the DTRA noted that the Board's remand did not request any action from the DTRA and that the Veteran "indicated that he was not exposed to radiation as a result of atmospheric nuclear testing from 1945 to 1962 or as a member of occupational forces in Japan following World War II."  The DTRA letter noted that it was advised by Department of Veterans Affairs Compensation and Pension Services that the inquiry should be returned and forwarded to the Director, Compensation and Pension Services, for submission to the Under Secretary.  

A January 2014 memorandum referred this claim to the Under Secretary for an opinion pursuant to 38 C.F.R. § 3.311(b).  

A February 2014 memorandum from the Director, Compensation Service, to the Under Secretary for Health notes the details of the Veteran's service, including his reports of ionizing radiation exposure, and describes the Veteran's DD Form 1141.  It describes the Veteran's pertinent medical history, noting that, in May 1997, the Veteran underwent direct laryngoscopy with biopsy, attempted transoral excision of right tongue base primary, tracheostomy, right modified radical neck dissection, and suprahyoid approach excision right base of tongue, and that pathology diagnosed squamous cell carcinoma, aggressive basaloid, base of tongue.  It was noted that the metastatic squamous cell carcinoma involves two middle jugular lymph nodes, one of which was previously excised, the other is an intramuscular lymph node.  It was noted that the disease was diagnosed as poorly differentiated squamous cell carcinoma, stage T1N2B.  It was noted that the Veteran's DD Form 214 indicates that the Veteran is a Caucasian, male, 73 inches in height, 185 pounds, a United States citizen, and married.  It was noted that the Veteran's post-service employment is not identified.  He had a 12-year of history of smoking when young, and his family history is positive for lung cancer.  The Under Secretary was asked to review the Veteran's records and prepare a dose estimate, to the extent feasible, based on available methodologies.  Upon preparation of the estimate, the Under Secretary was asked to provide an opinion whether it is likely, unlikely, or as likely as not that the Veteran's cancer of the right base of the tongue and oral pharynx is the result of occupational exposure to ionizing radiation in service.  

A June 2014 memorandum from the Director, Post 9-11 Era Environmental Health Program, writing for the Under Secretary, to the Director, Compensation Service, notes the pertinent facts of the Veteran's case and states that an inquiry was placed to HQ, Air Force Safety Center, Weapons Safety Division.  The reply notes that the Air Force "periodically conducted radiation exposure evaluations on individuals and operations involving nuclear weapons."  It noted that "[t]hese studies have consistently demonstrated that AF exposures are low, typically well below 100 mrem in a year, with the exception of personnel that performed nuclear warhead  maintenance operations on a routine basis."  It noted that, "[e]xcept for special studies, monitoring of weapons personnel during the veteran's service time was infrequent."  It also noted that the Veteran's personnel records contained a DD Form 1141 and that the Air Force's Master Radiation Exposure Repository did not contain any records on the Veteran.  

The Air Force Safety Center e-mail also noted that, during the Veteran's period of service, Castle and Mather Air Force Bases "were Strategic Air Command (SAC) bases and would have been nuclear-capable."  However, "security force personnel were neither required nor allowed close-proximity contact with the nuclear weapons which was necessary to acquire an occupational-level radiation exposure."  The e-mail noted that, "[f]or nuclear munitions stored in igloos, inherent shielding provided by storage structures precluded exposure to personnel at exterior locations."  While "[s]ome SAC bases maintained bombers loaded with nuclear munitions in alert status [which] required security force protection, ... security force personnel were required to maintain a minimum separation distance between aircraft and security force vehicles."  According to the e-mail, "[a]t the minimum separation distance, radiation emissions from nuclear warheads would have been indiscriminable from background radiation sources."  

The Air Force Safety Center e-mail also noted that the Veteran's DD Form 1141 annotation of "CP-95" makes it apparent that the Veteran was assigned a DT-60 accident dosimeter, and that the August 1962 reading was the baseline reading, which it likely the same reading that it had at issue.  The e-mail also noted that "many nuclear-capable units issued DT-60 accident dosimeters to their workers as a precaution for an unlikely occurrence of an accidentally high radiation exposure, from perhaps a nuclear criticality."  The DT-60 accident dosimeters "would have been insensitive to the relatively low exposures received by nuclear weapons maintenance and other technicians that worked in these facilities."  It also noted that the minimum sensitivity of these dosimeters was approximately 10 Roentgen, which "is twice the current annual exposure limit for occupationally-exposed workers, and orders of magnitude higher than natural background doses during a standard monitoring period of weeks to months."  It was also noted that "the US has never experienced a high radiation exposure from a fielded nuclear weapon."  The e-mail concluded that "due to the lack of exposure potential, we have no dose recommendation for the veteran."  

Based on the Air Force Safety Center e-mail, the Director, Post 9-11 Era Environmental Health Program, "assign[ed] a dose of 100 millirem per year for a total dose of 600 millirem (0.6 rem) for the approximate 6 years of the Veteran's service in the Air Force."  

The Director then noted that, according to the Health Physics Society, in a position statement PS010-2, "Radiation Risk in Perspective," which was revised in July 2010, "'in accordance with current knowledge of radiation health risks, the Health Physics Society recommends against quantitative estimation of health risks below an individual dose of 5 rem in one year or a lifetime dose of 10 rem above that received from natural sources.'"  The position statement further states that "'there is substantial and convincing scientific evidence for health risks following high-dose exposure.  However, below 5-10 rem (which includes occupational and environmental exposures), risks of health effects are either too small to be observed or are nonexistent.'"  

The Director concluded by stating that, "[s]ince the Veteran's radiation dose did not exceed 5 rem in one year or 10 rem in a lifetime, it is our opinion that it is unlikely that his cancer of the right base of the tongue and/or oral pharynx can be attributed to radiation exposure while in military service."  

In a June 2014 opinion, the Director, Compensation Service, noted review of the claims folder, including the June 2014 memorandum from the Director, Post 9-11 Era Environmental Health Program (DEHP).  Following a description of this evidence, the Director, Compensation Service, concluded that "[a]s a result of this opinion, and following review of the evidence in its entirety, it is our opinion that there is no reasonable possibility that the veteran's cancer of the right base of tongue and/or oral pharynx can be attributed to exposure to ionizing radiation in service."  

In response to this opinion, the Veteran submitted an October 2014 statement disputing the estimated dose of 100 millirem per year.  He believed that this dosage would be very low "[i]f it was based on a dosimeter reading," as "[b]ack in the day most of us AF guys never carried them with us."  The Veteran then noted that he "was exposed to atomic weapons and did spend time in the atomic weapons bunker storage area and was also exposed to atomic weapons on the flight line around B-52's."  

The Board notes that the above dosage estimate was not based merely on a dosimeter reading, but was based on the Air Force Safety Center's description of the levels of ionizing radiation exposure that was received by individuals who performed the same duties that were performed by the Veteran during the Veteran's era of service.  This estimate was based in part on the Air Force Safety Center's knowledge of storage practices of nuclear weapons at nuclear-capable SAC bases.  The e-mail also included a description of the purpose and sensitivity levels of the DT-60 dosimeter, explaining that this badge would have been, by design, insensitive to routine levels of radiation that were emitted from nuclear weapons but would have recorded radiation levels emitted during an accidentally high radiation exposure.  It was also noted that "the US has never experienced a high radiation exposure from a fielded nuclear weapon."  Based on this information, it appears that the type of exposure that would have been necessary to record a reading on the DT-60 badge would have been unprecedented for individuals working with fielded nuclear weapons.  The Air Force Safety Center appears to have cited to the DT-60 readings for the purpose of demonstrating that the Veteran was not exposed to radiation emissions at the level of a nuclear criticality.  The actual dosage estimate is based more directly on the methodologies that are described above and in the June 2014 memorandum from the Director, Post 9-11 Era Environmental Health Program, to the Director, Compensation Service, rather than on a dosimetry reading.  

Given the official finding above obtained pursuant to the required special processing of claims involving radiogenic diseases, the Board finds that service connection for residuals of squamous cell carcinoma at the base of the tongue/oral pharynx is not warranted with application of the provisions of 38 C.F.R. § 3.311 alone.  See Ramey, supra.  The June 2014 formal opinion of the Director, Post 9-11 Era Environmental Health Program, obtained in the manner prescribed by 38 C.F.R. § 3.311, finds that the Veteran was not exposed to a sufficient level of radiation during service to be reasonably medically linked to causing squamous cell carcinoma at the base of the tongue/oral pharynx.  This evidence is highly probative, weighs against the claim, and is uncontradicted by any other competent evidence on the point.  In short therefore, service connection for squamous cell carcinoma at the base of the tongue/oral pharynx cannot be granted under 38 C.F.R. § 3.311.

As stated above, under Combee, VA must not only determine whether a Veteran had a disability recognized by VA as being etiologically related to exposure to herbicides or ionizing radiation under the regulatory presumptions of 38 C.F.R. §§ 3.307, 3.309 and 3.311, but also must determine whether the disability was otherwise the result of active service.  The Board notes initially that because the Veteran's squamous cell carcinoma at the base of the tongue/oral pharynx was first identified many years after service in 1997, entitlement to service connection with application of the presumptions with regard to 'chronic' disabilities under 3.309(a) is not warranted.  Under these presumptions, service connection for cancer may be granted if demonstrated to a compensable degree within one year of service.  In this case, the squamous cell carcinoma at issue is not shown clinically prior to 32 years after service; the Veteran himself has asserted that his squamous cell carcinoma began in 1997.

With respect to entitlement to service connection for squamous cell carcinoma at the base of the tongue/oral pharynx without the application of any statutory or regulatory presumption, the Board notes that the Veteran's service treatment records contain no evidence of pertinent complaints or treatment.  Nor are there complaints or medical evidence of squamous cell carcinoma for decades following his separation from service.  The lengthy period following service prior to any shown manifestation of squamous cell carcinoma at the base of the tongue/oral pharynx weighs against a direct theory of service connection.  See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000).  Furthermore, the only etiology opinion in support of the Veteran's claim comes from the Veteran himself.  The Board recognizes the Veteran's contentions and acknowledges the Veteran's own belief that his squamous cell carcinoma at the base of the tongue/oral pharynx is causally connected with his time in service.  However, while the Veteran as a lay person is competent to provide evidence regarding injury and symptomatology, the question of whether the Veteran's squamous cell carcinoma is related to in-service exposure to ionizing radiation is of sufficient medical complexity that he is not competent to provide evidence regarding diagnosis or etiology.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  

In short, the Board finds that a preponderance of the evidence is against finding that the Veteran's squamous cell carcinoma at the base of the tongue/oral pharynx is etiologically related to his military service, to include exposure to ionizing radiation.  As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and the claim for service connection for residuals of squamous cell carcinoma at the base of the tongue/oral pharynx must be denied.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990).


ORDER

Entitlement to service connection for residuals of squamous cell carcinoma at the base of the tongue/oral pharynx, to include as a result of exposure to ionizing radiation, is denied.




____________________________________________
WAYNE M. BRAEUER
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs