Citation Nr: 0809979 Decision Date: 03/26/08 Archive Date: 04/09/08 DOCKET NO. 05-37 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for residuals of postoperative esophageal cancer, secondary to service- connected duodenal ulcer. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Johnston, Counsel INTRODUCTION The veteran had active military duty from May 1954 to April 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The case is now ready for appellate review. FINDINGS OF FACT 1. All relevant evidence necessary for a fair and equitable disposition of the appeal has been requested or obtained. 2. There is a complete absence of any competent medical evidence or opinion which in any way supports the veteran's claim that his service-connected duodenal ulcer caused or aggravated his esophageal cancer, and the only competent medical opinion on file is against the claim. CONCLUSION OF LAW Residuals of postoperative esophageal cancer are not secondary to or aggravated by the veteran's service-connected duodenal ulcer. 38 U.S.C.A. §§ 1110, 1131, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION Law and Regulation: VCAA and regulations implementing this liberalizing legislation are applicable to the veteran's claim. VCAA requires VA to notify claimants of the evidence necessary to substantiate their claims, and to make reasonable efforts to assist claimants in obtaining such evidence. The veteran was provided formal VCAA notice in November 2004, prior to the issuance of the rating decision now on appeal from January 2005. That notice informed him of the evidence necessary to substantiate his claim, the evidence he was responsible to submit, the evidence VA would collect on his behalf, and advised he submit any relevant evidence in his possession. Additionally, that notice specifically informed the veteran that he needed to submit medical evidence showing a causal connection between his cancer and his service- connected duodenal ulcer. The veteran already had a somewhat extensive claims folder. Records of the veteran's treatment and surgery for esophageal cancer and recent VA outpatient treatment records were collected for review. The veteran was also provided a VA examination with respect to his claim which is adequate for rating purposes. The veteran did not submit any clinical evidence or opinion in support of his claim, and in November 2004 wrote that he had no evidence to submit. VCAA is satisfied. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service connection may be established for disease or injury incurred or aggravated or otherwise attributable to incidents of military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. This is referred to as secondary service connection. 38 C.F.R. § 3.310(a). Additionally, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service- connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). Analysis: The veteran filed his claim for secondary service connection for his postoperative esophageal cancer in October 2004. In several written statements, he argued that his longstanding, service-connected duodenal ulcer caused or contributed to his esophageal cancer. Although he wrote that he had been told this was true by various doctors, and although requested to submit competent clinical evidence or opinions supporting his claim, the veteran submitted no medical statement from any physician or other competent evidence supporting his claim. Historically, the veteran was treated for duodenal ulcer during service in 1956, and in 1963 underwent a vagotomy. Duodenal ulcer was rated as 20 percent disabling from May 1962, and 40 percent disabling from March 1987. Prior to surgery for esophageal cancer in 2004, the veteran was examined for ulcer in February 2003. It was noted that he had been vitamin B12 deficient since the 1980's and had been taking vitamin B12 injections since that time. He underwent vagotomy in 1963 for treatment of ulcer. Since that time, he had been on a bland diet for most of his adult life. He could not eat fried or spicy food or dairy products, and did not have any pain unless he ate the wrong type of food. The veteran denied a history of vomiting or hematemesis, but did have occasional melena when his hemorrhoids were acting up. At the time of examination, he denied using any treatment for ulcer. He denied any episodes of colic, distension, nausea or vomiting. He had an approximate five to ten pound weight loss over the previous five years. Blood work obtained in August 2002 had revealed no anemia. The diagnosis was history of gastric ulcer. In June 2005, the veteran was provided a VA examination. The claims folder was unavailable, but it was noted the veteran had extensive computer files available from 1996 to present, "which were viewed." Laboratory studies were performed as was a CT scan of the chest. The examiner noted that the veteran had smoked tobacco for 40 plus years, and stopped smoking in September 2004. The veteran had begun to loose weight in 2001, and diagnostic studies located a squamous cell carcinoma of the esophagus. He underwent surgical intervention for removal of the cancer in 2004 without any associated radiation treatment or chemotherapy. There is no evidence of recurrence. Again, there was no notation of reflux or regurgitation or nausea or vomiting. The diagnosis was status-post esophagotomy with colonic interposition completed in October 2004 for squamous cell carcinoma of the esophagus. The examiner wrote that esophageal cancer was not caused or related to the veteran's service-connected duodenal ulcer from 1956. The examiner wrote that several types of malignant cancers occur in the mouth and throat, and that squamous cell carcinoma was the most common type. The examiner wrote that tobacco use was by far the most common risk factor for cancers of the mouth and throat, some six times higher than rates for nonsmokers. Finally, the examiner noted that from 1996 to present, there were not clinical records or any evidence demonstrating any significant symptoms of stomach discomfort, until the veteran began to have noticeable symptoms from his esophageal cancer in 2001. A clear preponderance of the evidence on file is against the veteran's claim for service connection for the residuals of postoperative squamous cell carcinoma of the esophagus secondary to or aggravated by his service-connected duodenal ulcer. Although the veteran claims such causal connection and has reported that doctors have told him there is a causal connection, the veteran did not submit any competent clinical evidence or opinion supporting his claim. There is, in fact, a complete absence of any evidence of a causal connection between longstanding treated duodenal ulcer and the more recent onset of squamous cell carcinoma of the esophagus. Treatment records of the veteran's longstanding ulcer do not reveal chronic irritation of the esophagus, gastroesophageal reflux, vomiting, hematemesis or other aggravation of the esophageal passage. The February 2003 VA examination for ulcer noted the existence of prior anemia, but found no current anemia and no significant symptoms from ulcer, other than adverse reaction to improper diet. The June 2005 VA examination resulted in a clinical opinion that there was no causal connection between the veteran's service-connected ulcer and his esophageal cancer. Further, this report noted the veteran's 40-plus year history of smoking tobacco through 2004, and pointed out that tobacco use was by far the most common risk factor for cancers of the mouth and throat. This is the only competent clinical opinion on file, and it is solidly against the veteran's claim. The representative has argued that the VA examination provided the veteran did not include a review of the claims folder and was therefore inadequate. The Board disagrees. The examiner noted that the veteran had extensive computer files available from 1996 to present and noted that these were thoroughly reviewed. Furthermore, under the circumstances presented in this case, the Board finds that no VA examination was warranted or required under VCAA at 38 U.S.C.A. § 5103A(d). That law states that if there is evidence of current disability and also includes evidence that this current disability "may be associated with the claimant's active military...service", but does not contain sufficient medical evidence for a decision, then an examination with record review and request for opinions is required. In this case, although there was certainly evidence of postoperative residuals of esophageal cancer, there was an essential absence of any competent clinical evidence or opinion which in any way showed or suggested that esophageal cancer was in any way caused or aggravated by the veteran's service-connected duodenal ulcer. The veteran's statements arguing such connection are certainly not competent as the veteran lacks the requisite medical expertise to provide any form of a competent clinical opinion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Accordingly, there was no duty under VCAA to provide the veteran with an examination of any kind with respect to this claim. An examination was provided, nonetheless, and although the claims folder was not available, the examiner was able to review a comprehensive clinical history from 1996 forward, and this covered the period of first identifiable symptoms for esophageal cancer in 2001, through surgery in 2004, up until present. ORDER Entitlement to service connection for postoperative residuals of esophageal cancer secondary to service-connected duodenal ulcer is denied. ____________________________________________ F. JUDGE. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs