Citation Nr: 0833602 Decision Date: 09/30/08 Archive Date: 10/07/08 DOCKET NO. 03-28 896A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Sean A. Kendall, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J.G. Reinhart, Associate Counsel INTRODUCTION The veteran served on active duty from May 1967 to August 1971. He died in June 1984. The appellant is the veteran's surviving spouse. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In January 2004, the appellant testified at a personal hearing before a Decision Review Officer (DRO). In her October 2003 substantive appeal, the appellant requested a hearing before a member of the Board. In January 2004, she withdrew that request. She had previously testified before the Board in a May 2002 video conference hearing. Transcripts of the January 2004 DRO hearing and the May 2002 Board hearing are of record. In November 2005, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington DC. to obtain a medical opinion. That action completed, the matter was properly returned to the Board. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In November 2006, the Board issued a decision addressing this matter. Subsequent to that decision, the appellant filed an appeal with the United States Court of Appeals for Veterans Claims (Court). In an Order dated in March 2008, the Court granted a joint motion of the appellant and VA's General Counsel to vacate the November 2006 decision and remand the matter to the Board for readjudiction consistent with the Joint Motion. In September 2008, the appellant, through counsel, submitted a medical opinion and associated evidence from "C.N.B.", M.D. This evidence has not been reviewed by the RO. However, in a letter accompanying that evidence, the appellant waived RO consideration of that evidence. Hence, the Board has considered all evidence of record, irrespective of when submitted. See 38 U.S.C.A. § 20.1304(c) (2007). FINDINGS OF FACT 1. The veteran died in June 1984; a Certificate of Death lists the cause of death as respiratory arrest due to increased intracranial pressure due to grade III Astrocytoma left cerebral hemisphere. The appellant is the veteran's surviving spouse. 2. At the time of the veteran's death service connection had not been established for any disability. 3. The disease that caused the veteran's death was not caused or aggravated by exposure to herbicide agents during active service. 4. The disease that caused the veteran's death did not have its onset during his active service, did not manifest within one year of separation from active service, and is not otherwise linked to his active service. CONCLUSION OF LAW The criteria for service connection for the cause of the veteran's death have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1310, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The basis for the Court's May 2008 Order remanding this matter, succinctly stated in the Joint Motion, is for the Board to ensure compliance with its duty to assist and with its previous remand orders. Joint Motion at 8. While this is somewhat unclear, the Joint Motion stated several points that inform the meaning of that statement. The Parties agreed that the Board did not provide sufficient reasons for why the Board found the opinions that were favorable to the appellant's claim, those of "H.A.D.", M.D. and "R.A.F.", M.D., to have less probative weight than a July 2003 opinion rendered by a VA physician. Id. at 6. Furthermore, the Joint Motion stated that the Board decision relied on an August 2004 VA medical opinion after having remanded the matter in November 2005 to obtain another opinion. Id at 5. Finally, the Joint Motion stated that the Board's express directives in the November 2005 remand were not carried out. Id at 7. Although it is unclear as to why this is so, it appears that the problem is that the Board did not sufficiently explain its analysis of the medical opinion evidence of record. Id. The basis of the joint motion is not clear. In this regard, the Board finds that no additional development is necessary. Sufficient evidence is of record for the Board to make a decision in the matter. The Board reviews the evidence de novo and will endeavor to provide detailed reasons and bases for its decision in this document. By these detailed reasons and bases, the Board will ensure that there has been compliance with VA's duty to assist and compliance with the Board's November 2005 Remand. Dependency and indemnity compensation may be awarded to a veteran's spouse, children, or parents for death resulting from a service-connected or compensable disability. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. In order for service connection for the cause of the veteran's death to be granted, it must be shown that a service-connected disorder caused his or her death, or substantially or materially contributed to it. A service-connected disorder is one that was incurred in or was aggravated by active service. Death is deemed to have been caused by a service- connected disability when the evidence establishes that a service- connected disability was either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a). Service- connected disability is deemed to have been the principal cause of death when it, singly or jointly with another disorder, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). In determining whether a service-connected disability was a contributory cause of death, it must be shown that a service- connected disability contributed substantially, materially, or combined with another disorder to cause death, or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c); see Harvey v. Brown, 6 Vet. App. 390, 393 (1994). Therefore, service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. Certain chronic diseases, including malignant tumors, may be presumed to have incurred in service, although not otherwise established as such, if manifested to a degree of 10 percent or more within one year of the date of separation from service. 38 U.S.C.A. § 1112(a)(1) (West Supp. 2007); 38 C.F.R. § 3.307(a)(3) (2007); see 38 U.S.C.A. § 1101(3) and 38 C.F.R. § 3.309(a). VA regulations also provide that if a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected, if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostrate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); and, soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2007). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. In this regard, the Board observes that VA has issued several notices in which it was determined that a presumption of service connection based upon exposure to herbicides used in Vietnam should not be extended beyond specific disorders, based upon extensive scientific research. See, e.g., 68 Fed. Reg. 27,630-27,641 (May 20,2003); 67 Fed. Reg. 42600 (June 24, 2002); 66 Fed. Reg. 2376 (Jan. 11, 2001); 64 Fed. Reg. 59232 (Nov.2 1999). A veteran, who during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii) (2007). Presumptions under 38 U.S.C.A. § 1112 and § 1116 are rebuttable. Where there is affirmative evidence to the contrary, or evidence to establish that an intercurrent disease or injury which is a recognized cause of any of the diseases or disabilities within the purview of § 1112 or §1116, has been suffered between the date of separation from service and the onset of any of such diseases, service connection pursuant to § 1112 or § 1116 will not be in order. 38 U.S.C.A. § 1113(a). This case involves weighing competing medical opinions. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). As to the Board's determinations regarding credibility, the Federal Circuit has stated "This is not to say that the Board may not discount lay evidence when such discounting is appropriate. Rather, the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc." Buchanan v. Nicholson, 451 F3.d 1331, 1336-37 (Fed. Cir. 2006). Specific to evaluating medical opinion evidence, in Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the Court stated: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . Important for this case, and as stated by the Court itself, the credibility of medical opinion evidence is within the province of the Board. So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Greater weight may be placed on one examiner's opinion over another depending on factors such as reasoning employed by the examiners and whether or not, and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). There is a long line of cases that establish that speculative medical opinions are of little probative value. See Bloom v.West, 12 Vet. App. 185 (1999); Stegman v. Derwinski, 3 Vet. App. 228 (1992); Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In this decision, the Board finds that the medical opinion evidence from Dr. C.N.B., Dr. R.T.F., and Dr. H.A.D. is of little probative value because this evidence is speculative, explanations for the conclusions are poorly reasoned, and the evidence is not credible. The Board also finds that the medical opinion evidence provided by VA practitioners in July 2003, August 2004, and April 2006 is of high probative value because the conclusions are supported by clear, logical, and compelling reasoning and because the evidence is not speculative and is credible. Additionally, the Board finds that the June 1984 pathology report signed by "E.DM.", M.D." is of high probative value because it is the only item of evidence providing direct medical diagnostic evidence of the disease that caused the veteran's death. The history of the medical opinions supporting the appellant's claim evolve habitually. As will be explained below, the medical opinion evidence offered to support the appellant's claim: (1) began with opinions that the veteran's brain tumor was properly diagnosed as a Grade III astrocytoma that may have been related to exposure to herbicides during service; (2) progressed to an opinion that the astrocytoma is a first cousin to soft tissue sarcoma and, thus, should presumed under VA regulation to have been due to exposure to herbicides; (3) to an opinion that the veteran's tumor was not astrocytoma at all, but actually rhabdomyosarcoma (a soft tissue sarcoma subject to presumptive service connection), and then finally; (4) back to an opinion that the tumor was not a soft tissue sarcoma but should be considered as a result of herbicide exposure because some other types of tumors are considered to be the result of herbicide exposure. The veteran died in June 1984. Of record, is a certificate of death listing the immediate cause of the veteran's death as respiratory arrest due to or as a consequence of increased intracranial pressure, due to, or as a consequence of Grade III astrocytoma left cerebral hemisphere. During the veteran's lifetime, service-connection had not been established for any disability. The appellant contends that the condition leading to the veteran's death was caused by exposure to the herbicide agent "Agent Orange" during his active service. Service medical records are absent for any mention of cancer of symptoms of a tumor. The first evidence of a malignant tumor comes in the terminal treatment notes from June 1984, many years after service. This is evidence against a finding that the veteran's malignant tumor had its onset during service or manifested within one year of separation from active service. A June 1984 operation record indicates that Dr. R.T.F. was the attending physician and signed the Certificate of Death as the certifying physician. Dr. R.T.F. also signed a hospital summary. That summary provided that the veteran was admitted after experiencing headaches for several weeks. The veteran underwent a craniotomy which revealed a malignant tumor of the brain. He died one day later. Dr. H.A.D. was the surgeon who signed the report of the operation that removed the veteran's brain tumor. Dr. E.D.M. signed a pathology report of analysis and diagnosis of the biopsied tissue. The operation report states that the symptoms experienced by the veteran prior to the operation indicated a high grade quickly growing glioma of the cerebrum. Dr. E.D.M. reported that microscopic analysis of three biopsied specimens, each labeled "brain tumor", showed that the lesion was classified as an astrocytoma Grade III, also known as an anaplastic astrocytoma. He also reported that some of the tissue suggested a diagnosis of glioblastoma multiforme, but that the overall characteristics of the tumor were not usual for a frank glioblastoma. Dr. E.D.M. stated that some authors consider astrocytoma of Grade III and IV within the category of glioblastoma. The final diagnosis was Astrocytoma Grade III. The Board notes that the pathology report is the only diagnostic evidence of record deriving directly from the veteran's tumor. Dr. E.D.M.'s medical opinion is the only opinion based on microscopic analysis of the tissue removed from the veteran. All other opinions come as secondary interpretations of that report. In a letter dated in July 1984, Dr. H.A.D. stated that he become aware of the veteran's service in Vietnam. Dr. H.A.D. also reported that the veteran had a hyperactive child. This physician expressed curiosity as to the veteran's brain tumor and, what he termed an obvious central nervous system disorder of the veteran's child, as evidenced by the child's hyperactivity. Dr. H.A.D. stated that "[m]any have over the past several years linked the chemical in response to nervous system disease in offspring as well as primary malignant tumors such as one encountered in [the veteran's] case." This physician stated his opinion that the veteran's case should be considered along with other cases in review as to the Agent Orange issue as to etiology. Dr. H.A.D.'s July 1984 letter is an opinion that research into etiological relationships between nervous system disorders, including brain cancer, should take into account the veteran's case, particularly given the disease of his child. The Board finds that this is not a statement of causation, but merely of speculation as to possible links between the veteran's brain cancer and his child's hyperactivity, which Dr. H.A.D. characterized as a congenital central nervous system disorder. Dr. H.A.D.'s rational was, at that time, that: (1) the veteran had brain cancer; (2) his child is hyperactive; and (3) and since both have to do with the central nervous system, it follows that exposure to Agent Orange could have caused the veteran's brain cancer. The basis for this logic is found to be very unclear. The Board finds that this poor reasoning reduces the weight assigned to this opinion greatly. Of note is that in the July 1984 letter, Dr. H.A.D. did not (at that time) deviate from the finding that the veteran's tumor was a malignant astrocytoma, nor make any mention of a soft tissue sarcoma. Indeed, he referred to the tumor as an astrocytoma. The RO denied the appellant's claim for VA benefits for service connection for the cause of the veteran's death in September 1984, August 1995, and September 1999. The September 1984 rating decision, an October 1984 Statement of the Case, and the August 1995 rating decision did not mention the term "soft tissue sarcoma." The first mention of that term found in the claims file is in the September 1999 rating decision that new and material evidence had not been submitted to reopen the appellant's claim. Following the September 1999 rating decision that first mentioned soft tissue sarcoma is a September 2000 letter in which Dr. H.A.D. stated that the astrocytoma Grade III is a first cousin to a soft tissue sarcoma "and is diagnosed as a soft tissue sarcoma by some." Dr. H.A.D. stated "it is probable that [the veteran's] exposure to herbicides/ Dioxin in Vietnam was the cause of this central nervous system primary tumor." The Board finds that based on review of the record as a whole, the timing of Dr. H.A.D.'s letter, taken with content of his previous letter, is evidence that he embellished the diagnosis to fit what was needed by the appellant to secure VA benefits. Hence the September 2000 letter does not contain an honest medical opinion based in medical science. Rather than simply an "astrocytoma", a diagnosis that did not meet the presumptive criteria for service connection, Dr. H.A.D. crudely attempts to fit the veteran's cancer into a category for which presumptive service connection applies. He provides vague support for this recharacterization with a statement that "some" would diagnosis an astrocytoma as a soft tissue sarcoma. Dr. H.A.D. finally states that it is probable that the veteran's exposure caused his tumor, but his statement is based on the veteran having died from the equivalent of a soft tissue sarcoma. Had the evidence showed that the veteran died from a soft tissue sarcoma, VA would likely have already granted service connection and the instant Board decision would be unnecessary. The regulations do not provide for presumptive service connection for first cousins to soft tissue sarcoma. This situation is this case is usually clear. Dr. H.A.D. made no mention of astrocytoma being related to soft tissue sarcoma in his 1984 letter. Thus (as is a pattern with most of the medical opinion evidence favorable to the appellant's claim in this case) Dr. H.A.D. merely changed his opinion and qualified the diagnosis to fit what he believed would provide for a grant of VA benefits for the appellant. This impacts negatively on the credibility of the September 2000 opinion. As to Dr. H.A.D.'s statement that it is probable that the veteran's exposure to herbicides caused his cancer, this opinion is unsupported other than by Dr. H.A.D.'s recharacterization of the veteran's astrocytoma. As such, it is only a conclusory statement without credible foundation and hence, is of only the slightest probative value. In this September 2000 letter, Dr. H.A.D. has done little more than argue that VA should extend presumptive service connection to other cancers that are something like the diseases for which the presumption applies. This is a medical opinion in form only. This significantly reduces the probative weight that the Board assigns to Dr. H.A.D.'s letter. Other evidence, submitted more recently in support of the appellant's claim, does further damage to this opinion. In a letter dated in May 2003, Dr. R.T.F. stated that an American Journal of Pathology article from February 2000 reported research findings that Grade III astrocytoma was "of an evolution of the sarcomatous component due to aberrant mesenchymal differentiation in a highly malignant astocytic neoplasm." Dr. R.T.F. stated that this article establishes that the veteran's tumor was a soft tissue sarcoma and therefore subject to the presumptive service connection provisions of VA regulations. Given the confusion arising from these opinions, the RO requested that a VA examiner review the claims file and render a medical opinion regarding the nature of the tumor that caused the veteran's death. "C.A.", M.D. rendered an opinion in July 2003, which stated in full as follows: C-file was reviewed. The pathology report of 06/20/84 revealed the diagnosis of Astrocytoma, Grade III. The pathology report is the definitive statement of the cell type of the tumor. On complete review of the pathology report there is no mention of a sarcomatous component of the tumor. I pulled the article that was referenced by his doctor in the American Journal of Pathology of February 2000 and the title of the article is Genetic Profile of Gliosarcomas. The patient's pathology report is Astrocytoma and not Gliosarcoma. Astrocytomas are not a soft tissue sarcoma. This opinion does not identify the medical specialty practiced by Dr. C.A. However, a later opinion by Dr. C.A., dated in April 2006, indicates that this physician practices in the field of medical oncology. Dr. C.A.'s practice in the field of medicine dealing specifically with the diagnosis and treatment of cancer adds probative weight to her opinion. Also adding weight to Dr. C.A.'s opinion is her clear and logical reasoning. Dr. C.A. provides two compelling reasons for why the veteran did not have a soft tissue sarcoma. First, her reasoning that the pathology report created at that time of the veteran's death is the controlling data is highly probative. Not only is this the only objective evidence of record of scientific analysis of the tumor tissue, but the pathology report was created at a time when there was no motivation to state other than the truth as to the nature of that tumor. All other interpretations of the veteran's tumor are without the benefit of actually viewing the biopsied tissue. At best, the diagnoses that deviate from that of the pathologist who viewed the tissue are speculation and interpretation of Dr. E.D.M.'s language as to what the microscopic appearance of the tissue. The second compelling reason given by Dr. C.A. is that there was no mention of a sarcomatous component in the tumor in that definitive pathology report and the entire foundation for Dr. R.T.F.'s opinion is a journal article dealing with a type of cancer the veteran did not have. This appears to indicate that Dr. R.T.F. was engaging in deception in his May 2003 letter. He sought to add weight to his opinion by bolstering it with an inapplicable citation. The Board finds that this is a trend throughout the evidence presented in support of the appellant's claim. In light of the actions of the Court in this case, the Board believes it must be clear on this point: The Board finds that the medical opinions favorable to the appellant's claim amount to half truths, embellishments, obfuscations, untruths, and deceptive misapplication of cited sources to support the opinions. Dr. R.T.F. submitted another letter to VA dated in January 2004. That letter, in its entirety is as follows: Primary Atrocytomas [sic] usually occur in older people and contain epidermal growth factor. Secondary Astrocytomas are usually seen in younger people and are more malignant. They have been found to have certain mutations of the genes caused by "something"; hence it is considered a secondary Astrocytoma. The more the mutations caused by "something" the more malignant and aggressive the malignant astrocytoma becomes. Rarely the mutations are so extensive that sarcomatous changes develop. It follows that the Astrocytoma Grade III (Malignant Tumor) was caused by genetic mutations induced by "something" such as Agent Orange, and it is in the same family of malignancies as the gliosarcoma. (Most pathologists haven't heard of this). In this letter, Dr. R.T.F. shifts to a new theory, apparently having abandoned his previous theories since those were not fruitful. Dr. R.T.F.'s rationale in the May 2003 letter is flawed, making two poorly reasoned leaps to arrive at his conclusion. First, by his own language, that this rarely occurring mutation leading to sarcamatous changes occurred in the veteran's case. Second, that since "something" causes these mutations, that "something" is likely exposure to Agent Orange. Finally, he points to no evidence that the veteran had a genetic mutation, apparently just arriving at that important basis for his opinion because it was necessary to support his already flawed reasoning. There is no mention of genetic mutations in the pathology report. Dr. R.T.F.'s poor and contrived reasoning reduces the probative weight to be assigned to his May 2003 opinion. Finally, his statement that most pathologists are not privy to this apparently esoteric knowledge further lessens the weight of his opinion because he seeks to apply knowledge that, by this very admission, is not part of standard practice. In March 2004, Dr. H.A.D. submitted another letter in support of the appellant's claim. The first two paragraphs say nothing about the nature of the veteran's tumor. The third paragraph, the last sentence of the fourth paragraph, and a final standalone sentence comprise Dr. H.A.D.'s opinion. In their entirety, these are as follows: It is my medical opinion that the pleomorphism and the abundant eosinophilic cytoplasm makes the diagnosis that of rhabdomyosarcoma (a soft tissue sarcoma) (Youmans, Pathology of Gliomas Including Tumors of Neuronal Origin Vol. I, page 614). The attached Pathology Report describes marked differentiation in large cells and small cells consistent with [the veteran's] rhabdomyosarcoma. It is almost a certainty that [the veteran's] exposure to herbicide/Dioxin in Vietnam was the cause of this tumor. It is further almost a certainty that [the veteran] developed this soft tissue sarcoma during his military career and it slowly progressed. Dr. H.A.D., a surgeon, not a pathologist or an oncologist, fails to explain why he did not diagnose rhabdomyosarcoma in 1984, but instead, according to his letter, allowed a supposed misdiagnosis to stand and be recorded on the Certificate of Death. Dr. H.A.D. also fails to explain why the pathologist, from whose report Dr. H.A.D. now draws language in support of his most recent diagnosis, did not provide the diagnosis that Dr. H.A.D. now proposes. Again, stripped of the medical jargon that seeks to imply an air of scientific validity in the third paragraph of his letter, the letter amounts to no more than a statement that the veteran had soft tissue sarcoma and was misdiagnosed in 1984. Dr. H.A.D. makes this assertion without the benefit of viewing tissue from which the 1984 pathology report was derived. Furthermore, Dr. H.A.D. selectively pulls words from the pathology report but fails to explain the other findings in the report. He makes no mention of the vast majority of Dr. E.D.M.'s explanation. The selective extraction of words from the report without further explanation is a deceptive exercise in making the data fit a diagnosis rendered 20 years after the fact rather than fitting the diagnosis to the data. Stripped of the obfuscating language, this is all that Dr. H.A.D.'s letter accomplishes. The Board finds that the letter is of limited probative value. Faced with this additional influx of confusing evidence, in August 2004 the RO requested another medical opinion. Specifically, the RO requested that a qualified physician review the veteran's claim file. The RO requested that the physician indicate whether or not the condition that caused the veteran's death (Grade III Astrocytoma) is considered a type of soft tissue sarcoma and to state whether the veteran's tumor first began during his active military service. This request also noted that Dr. "A." had provided a medical opinion on this issue in July 2003 but that since that opinion was rendered, the claimant had submitted medical opinions and research materials on the subject. The RO went on to add that "we need a qualified physician to review this additional evidence and provide a new opinion. It is important for the appellant (and the Court) to understand that the request for an additional medical opinion by the RO (or for that matter, later by the Board in its November 2005 Remand) does not, in and of itself, render the other opinions without value. The request for additional opinions is only an indication that the existing opinions did not completely resolve the questions of the VA adjudicators or that additional evidence had been submitted that raised new questions. Simply stated, an inadequate opinion is not necessarily a worthless opinion. Rather, an opinion inadequate as to one question, may provide completely adequate evidence when coupled with another opinion on that same question and may also provided probative and adequate evidence as to other questions in need of resolution. This is so in this case. A report dated in August 2004 contains the requested opinion. This examiner, "B.P." indicated review of the veteran's claims file. Reference was made to the pathology report executed in June 1984. This examiner indicated that the report was not ambiguous, and that all descriptions of the slides at the time of the veteran's surgery and all description of the morphology of the cells at the time of surgery are consistent with an astrocytoma and that one could not classify this as a type of soft tissue sarcoma. This examiner stated that the pathology report had been reviewed by the staff pathologist, Dr. "H." who found no confusion as to the description as well as the diagnosis of the pathological slides at the time of the veteran's surgery and that all descriptions of the morphology of the cells done at the time were consistent with an astrocytoma, not a soft tissue sarcoma. P.B. also stated that the tumor would not have been present from the time of the veteran's service, ending in 1971, until 1984. She stated that this issue had been presented to a staff oncologist, Dr. "K." and that Dr. K was of the opinion that it would be highly unlikely that a grade I astrocytoma would have remained asymptomatic for 13 years prior to transformation to a grade III astrocytoma, resulting in the veteran's death. The examiner concluded that it would be shear speculation to state that the veteran's astrocytoma Grade III was existent 14 years prior to his death as a Grade I astrocytoma. B.P. did not list her professional credentials. As the RO requested an opinion from a qualified physician, VA presumes that the officials at the VA Medical Center performed their duties as expected. The Court has held that "there is a presumption of regularity which holds that government officials are presumed to have properly discharged their official duties." Ashley v. Derwinski, 2 Vet. App. 307, 308-09 (1992) (quoting United States v. Chemical Foundation, Inc. 272 U.S. 1, 14-15, 71 L. Ed. 131, 47 S. Ct. 1 (1926)). There is no evidence of record to rebut this presumption. As to the mention of consultation with a staff pathologist and a staff oncologist, the Board does not find that this detracts from the August 2004 medical opinion. Consultation between medical practitioners and specialists in different areas of medicine are not uncommon in the treatment of patients. It is common knowledge that patients do not typically speak directly to pathologists about their analysis, but instead a report is provided to the treating physician who then makes treatment decisions based on those reports. There is no reason to believe that the same standard applicable to rendering treatment to living patients is somehow deficient when applied to evaluating a diagnosis of a now deceased patient. The Board finds that the consultation only indicates the opinion should be given great probative weight. The Board finds the August 2004 VA opinion highly probative because the report is based on inspection of the claims file and, in particular, of the June 1984 pathology report by qualified medical professionals. This August 2004 report makes no mention of whether the veteran's astrocytoma was caused directly by exposure to herbicides, only that the veteran type of tumor removed from the veteran was an astrocytoma Grade III and not a soft tissue sarcoma and that the tumor would not have been present in any form during the veteran's service. In November 2005, the Board remanded this matter for additional development. The Remand order stated that an opinion as to the nature and etiology of the veteran's cause of death was to be obtained from a VA oncologist or a similar medical expert in cancer diagnosis and treatment. The Remand order and the explanation in the body of the Remand made clear that the Board was requesting this opinion to determine if the veteran's astrocytoma was caused by exposure to Agent Orange, not to determine whether his tumor was properly diagnosed in 1984. In that regard, the Remand order provided "the examiner should state whether the veteran's fatal astrocytoma is at least as likely as not the result of his herbicide exposure in Vietnam." As explained in the body of that REMAND, additional evidence was needed as to whether the veteran's tumor, which did not fall into the class of tumors subject to presumptive service connection due to exposure to herbicides, was directly caused by exposure to herbicides, without application of the presumption. This Remand was necessary to comply with the holding in Combee v. Brown, F.3d 1039 (Fed.Cir. 1994). A report is of record dated in April 2006 and signed by "[C.A.], M.D. Medical Oncology". This is the same Dr. C.A. that provided the July 2003 medical opinion. The Board sees no reason to discount her opinion merely because she had provided an earlier opinion in this matter. Dr. C.A. stated that she had reviewed the veteran's claims file. She stated that the medical opinions of VA examinations from July 2003 and August 2004 were reviewed as were the opinions of Dr. H.A.D. from March 2004, July 1984, and September 2000 and those of Dr. R.T.F. from January 2004 and May 2003. Dr. C.A.'s April 2006 opinion, in full, is as follows: C-file was reviewed. The medical opinions per VA exams of 07/17/03 and 08/10/04 were reviewed. The medical opinions of Dr. HAD of 03/08/04. 07/02/84 and 09/11/00 were reviewed. The medical opinions of Dr. RTF of 01/26/04 and 05/09/03 were reviewed. The official pathology report is the definitive statement of the type of cancer ie Astrocytoma, Grade 3. This is not a soft tissue sarcoma. Astrocytoma's are not a presumptive diagnosis for Agent Orange. There is no medical literature to support a link between his Astrocytoma and Agent Orange exposure. Our pathologist reviewed the pathology report for a previous opinion and the diagnosis was clearly Astrocytoma. There is no medical evidence or literature to link his Astrocytoma to his time in the military or exposure to Agent Orange. The opinions of his treating physicians are speculative. The Board finds that this opinion responded precisely to the Board's November 2005 Remand. Dr. C.A. complied with the Board's request in that she reviewed the claims file and specifically reviewed the opinions of record in support of the appellant's claim. She also provided an opinion as to whether Agent Orange directly (as opposed to presumptively) caused the veteran's astrocytoma. As evidenced by the words "Medical Oncology" following her name, Dr. C.A. specializes in the diagnosis and treatment of cancer. Thus, the November 2005 Remand order was complied with. That she added additional commentary as to the propriety of the initial diagnosis and in doing so referred to the August 2004 medical opinion does not result in a finding that her opinion failed to comply with the Board's November 2005 order. That she repeated some of her words from her July 2003 opinion does not detract from her April 2006 opinion. If the definitive evidence of the type of cancer that the veteran had is the pathology report that resulted from analysis of that tissue, then regardless of how many times Dr. C.A. states such, the statements do not somehow reduce the probity or adequacy of her opinion. Furthermore, the Board notes that substantial compliance satisfies the requirements discussed in Stegall. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). There is no doubt that Dr. C.A.'s April 2006 opinion substantially complied with the Board's November 2005 Remand. Dr. C.A.'s April 2006 opinion as to whether the veteran's astrocytoma was directly caused by exposure to Agent Orange does not, by its very language, depend on any earlier opinion. She states that there is no medical evidence or literature to link his astrocytoma to his service, including exposure to Agent Orange. This is a clear and compelling reason. The opinion is not lacking in rationale, the rationale is just not complicated. The statement that there is no medical or literature evidence of a nexus is a logical and sufficient reason for finding that there is no nexus. This collection of medical opinions from Dr. H.A.D. and Dr. R.T.F., when taken together is a study in proffering one theory after another, hoping that one results in the appellant being granted VA benefits. The theories started with opinions that the astrocytoma was correctly diagnosed, but was the result of exposure to Agent Orange. Once the appellant's claim was denied on the theory above, the they came up with another. The physicians stated that what the veteran's astrocytoma was very close to a soft tissue sarcoma. This was interspersed with a theory that the veteran's tumor had been present since service but had simply laid dormant. When this new theory did not result in a grant of service connection, the theory was again changed. At that point it was asserted that the veteran's astrocytoma was variously an unnamed soft tissue sarcoma, a cancer resulting from genetic mutations caused by exposure to Agent Orange, and finally, a rhabdomyosarcoma, a named soft tissue sarcoma. Depending on the theory, Dr. R.T.F. and/or Dr. H.A.D. either find that his tumor was: (1) dormant and slowly maturing or (2) that it was aggressive. Most recently, in September 2008, the appellant submitted a document entitled INDEPENDENT MEDICAL EVALUATION, dated in August 2008 and signed by Dr. C.N.B. Dr. C.N.B. provided a list of his credentials, including that he was double board certified sub specialist, a senior member of the American Society of Neur-Radiology, an attending level school of medicine associate professor, and had a masters degree in business administration. He also detailed his work experience and assured the Board that he was a competent actively licensed physician and had performed several hundred VA Independent Medical Examinations. Dr. C.N.B. stated that his opinion was to a high degree of medical certainty and included in parenthesis that this was "much more likely than not." He stated that he reviewed the veteran's C-file that had been provided to him by the veteran's attorney. Dr. C.N.B. also stated that his opinion was not "based solely on patient history, but rather I noted pivotal several entries in the medical record and service records because in order to make my opinion, I have carefully reviewed the following information : Service Medical Records Post service Medical records; Imaging reports, Other medical opinions; Medical literature review." In discussing Dr. C.N.B.'s medical opinion, the Board has also discussed language and findings contained in three texts - Veterans and Agent Orange Updates, from 1996, 2004, and 2006, authored by the Institute of Medicine of the National Academies. The Board commits no "Thurber violation" by this discussion. In Thurber v. Brown, 5 Vet. App. 119 (1993), the Court held that, in rendering a decision on a claim, the Board could not rely on evidence obtained or developed subsequent to the most recent statement of the case or supplemental statement of the case without first providing the claimant with reasonable notice of such evidence and the Board's intended reliance on the evidence. In this case, the appellant introduced the texts into evidence via Dr. C.N.B.'s reference of sources relied on: "Veterans and Agent Orange Updates IOM". Hence, the appellant, not the Board obtained the evidence and, since the appellant introduced that evidence, the appellant has notice of that evidence. The Board merely discusses that evidence. Dr. C.N.B. first defined astrocytoma as a generic term for a brain tumor and that the "High grade (4) form" was known as Glioblastoma multiforme (GBM)". Apparently Dr. C.N.B. has upgraded the veteran's tumor from Grade III to Grade IV without viewing the tissue. Thus, Dr. C.N.B. begins his opinion by making an assumption contrary to the record. However, this is the least of the problems with Dr. C.N.B.'s opinion. Needless to say, the Board rejects this unexplained change in diagnosis and finds that this redefinition without support impacts negatively on Dr. C.N.B.'s opinion. This is characteristic of Dr. C.N.B.'s entire opinion which, at its best, is speculation embellished by scientific language. Dr. C.N.B. opined that the veteran's cancer was caused by his exposure to Agent Orange during military service. He offered eight reasons for his opinion. The first three reasons are far from compelling. Those reasons are (1) the veteran entered the service fit for duty; (2) he was exposed to Agent Orange; (3) he developed GBM. As to reasons (1) through (3), these are a study in poor reasoning. Using Dr. C.N.B.'s logic all veterans who get a disease post-service should be awarded service- connection. This faulty reasoning is untenable. Reasons (4) and (5) must be discussed together as the reasons refer to the same data for support. In Reason (4) Dr. C.N.B. asserts that the results of a meta-analysis pertaining to Agent Orange and brain tumors showed "that many studies have a Relative Risk (RR) greater than or equal to one (1) which stratifies the VA's criteria for an as likely as not level of causation." He then referred to a particular study of 447 patients that had a relative risk (RR) of 1.2 and a 2005 study by Lee of 25 patients with an RR of 3.3. Dr. C.N.B. stated that these studies meet the VA's criteria at the "likely as not" level of causation. He reported that the studies with RR's of greater than 1 "support the concept that agent orange more likely than not causes brain tumors according to the IOM epidemiologic literature review below:" The only attachment to Dr. C.N.B.'s opinion is a copy of "Table 6-38" titled "Selected Epidemiologic Studies - Brain Tumors." Reason (5) is in its entirety as follows: "The large study, above, of 447 patients with a RR of 1.2 is very supportive data of a causative link between OA and brain tumor/GBM and IOM states on page 302 "...there are data to suggest an association between exposure to chemicals so interest and brain tumors..."" In his list of references, Dr. C.N.B. listed the "Veteran's and Agent Orange updates IOM". Table 6-38 is contained in Institute of Medicine of the National Academies, Veterans and Agent Orange Update 2006 (2007) (hereinafter IOM AO Update 2006). Dr. C.N.B. did not include any other information associated in that text. Dr. C.N.B. does not refer to the methods of the studies he relies on, rather he refers to a statistic and then states that the studies support the concept that Agent Orange more likely than not causes brain cancer. However, this statement as to strength of the association is contradicted by other language in his opinion and, most importantly, from the very source from which he extracted Table 6-38, the data that forms the foundation for his opinion. Dr. C.N.B.'s quote "there are data to suggest an association between exposure to chemicals of interest and brain tumors" expresses nothing of the sort of an as likely as not standard, but only an association. Much more damaging to Dr. C.N.B.'s opinion is the rest of the language connected to his quote, not to mention that he does not identify from where he obtained that quote, other than the page number, but rather implies that the quote was extracted from the IOM AO 2006 update (containing Table 6-38) and refers directly to the study of 447 patients; neither of which is true. Page 302 of the IOM AO Update 2006 update does not contain that language but rather contains a page of Table 6-7 dealing with colorectal cancer. Dr. C.N.B.'s quoted language in Reason (5) comes not from the IOM AO Update 2006, nor is the language applied to table 6-38 in the original or to the study involving 447 patients that he cites. Rather he pulls out of context language from another update, and instead of at least quoting the entire sentence from where he extracted the language, he inserts ellipses around his quote. When one views the language in its entirety, it is clear why Dr. C.N.B. has made these misrepresentations. The language replaced in ellipses contradicts his statements as to "a medical certainty". The quoted language is found on page 302 of Institute of Medicine of the National Academies, Veterans and Agent Orange Update 2004 (2005) (hereinafter the IOM AO Update 2004). On page 302 of IOM AO Update 2004, under a heading of "Conclusions" and subheading of "Increased Risk of Disease Among Vietnam Veterans" is, in full, as follows: Although there are data to suggest an association between exposure to the chemicals of interest and brain tumors and other nervous system tumors, the lack of exposure information on Vietnam veterans precludes quantification of any possible increase in their risk. By positioning selectively chosen words from the 2004 update next to a reference to the study of 447 patients, Dr. C.N.B. supports his opinion by proposing that this study of 447 patients, the most subjects of any study listed on Table 6- 38, is highly probative of a link between Agent Orange and brain cancer. The language he has quoted, in its true context, does nothing of the sort. Rather, the entire sentence containing the quoted language provides evidence that any association between brain cancer and Agent Orange is tenuous at best and certainly not "as likely as not." The language he quoted does not refer to the study of 447 pages. Dr. C.N.B. has merely lifted language out of context and placed it next to a reference to a study to which the language did not refer. This deceptive manipulation of evidence further reduces the weight assigned to Dr. C.N.B.'s opinion as it shows that his opinion is largely based in deception. Table 6-38, attached to Dr. C.N.B.'s opinion, is found on pages 426 through 430 of IOM AO Update 2006. Table 6-38 lists both the 2005 study by Lee and the study involving 447 patients. What Dr. C.N.B. has done is selected from Table 6- 38 the study with the largest number of samples and the study with the highest RR. The text also contains analysis and commentary from the IOM. Dr. C.N.B. has conveniently not included that commentary with his opinion. That commentary and analysis is found following Table 6-38 in the IOM AO Update 2006, on page 431, under a heading of "Vietnam- Veteran Studies". The text under this heading , in its entirety, is as follows: In the mortality update of the CDC VES through 2000, Boehmer et al. (2004) reported nine deaths from cancers of the meninges, brain, or other parts of the CNS (ICD-9 191-192) in the deployed and seven in the non-deployed (CRR = 1.19, 95% CI 0.44- 3.20). Pavuk et al. (2005) reported on the risk of cancer in the comparison group of the Ranch Hand cohort study. Only one case of brain or other CNS cancer was reported; the sparseness of the data preclude risk estimation. The Australian Vietnam Veterans Mortality and Cancer Incidence Studies (ADVA, 2005a,b) reported the risk of brain cancer in a cohort of 59,179 servicemen. The estimated risks of brain cancer (97 cases; SIR = 1.07, 95% CI 0.85-1.28) and brain-cancer mortality (99 cases; SMR = 0.95, 95% CI 0.76-1.13) were not significantly associated with service in Vietnam. The possibility that the comparisons with the general population might be influenced by a healthy-warrior effect was investigated in a separate study that compared the rates of brain and CNS cancer in deployed and non-deployed Vietnam veterans (ADVA, 2005c). Brain- cancer incidence (RR = 1.36, 95% CI 0.73- 2.56) and mortality (RR = 1.64, 95% CI 0.89-3.09) were not significantly associated with deployment to Vietnam. On page 443 of the IOM AO Update 2006, under a heading titled Conclusion is, in total: On the basis of detailed evaluation of the epidemiologic evidence from new and previously reported studies of populations with potential exposure to the compounds of interest, the committee concludes that the categorization in prior updates (limited or suggestive evidence of no association) should be revised to inadequate or insufficient to determine whether there is an association between exposure to the compounds of interest and brain cancer and other nervous system cancers. Simply stated, the Board finds that Dr. C.N.B. supports his opinion with a reference to a report that clearly contradicts his opinion. Even more egregious is that Dr. C.N.B. leaves out the commentary that is available with regard to the study of 447 patients to which he refers. When one looks at the IOM analysis of that study, it again is clear why Dr. C.N.B. omits the relevant statements. The only study in Table 6-38, pointed to by Dr. C.N.B., that lists 447 subjects and an RR of 1.2 is Blair et al... 1993 of US farmers in 23 states. As stated in Table 6-38, this study was reviewed in Update 1996. Institute of Medicine, Veterans and Agent Orange: Update 1996 (IOM AO Update 1996) includes on page 229 under a heading of "Update on the Scientific Literature", the following complete text with regard to that study: Since VAO, a number of new studies on brain cancer have been published. A PCMR study was performed for farmers of 23 states, using occupational information from death certificates (Blair et al., 1993). No information on individual exposures to herbicides was available. Based on 447 deaths due to brain cancer in white male farmers, the PCMR was marginally increased at 1.2 (CI 1.1-1.3). Based on much smaller numbers of brain cancer deaths, the rates were not elevated in other race or gender groups. The study that Dr. C.N.B. has cited as the principle support for his opinion involves persons whose individual exposure to herbicides is unknown. They were simply farmers who died of brain cancer. Contrary to Dr. C.N.B.'s disingenuously quoted assertion that "this is very supportive of data of a causative link between OA and brain tumor/GBM", the study of farmers whose exposure to the herbicides is unknown is not supportive of a link between Agent Orange exposure and the cancer suffered by the veteran. Dr. C.N.B. also referred to the study by Lee with an RR of 3.3, listed in Table 6-38. Dr. C.N.B. again leaves out the commentary by the authors of his supporting text, the IOM, which is found on page 431 following table 6-38 in the IOM AO Update 2006. After explaining how the responses were obtained that formed the study, the IOM authors stated "[t]he pronounced and systematic discrepancy (see Table 6- 38) between the results on subject-reported exposure (reduced ORs) and proxy-reported exposure (significantly increased ORs), however, underscores concern about recall bias and casts doubt on any interpretations." Hence, Dr. C.N.B.'s "to a medical certainty" finding is contradicted by the text in which he found his supporting table. This is evidence against assigning more than minimal probative weight to Dr. C.N.B.'s opinion. Reasons (4) and (5), embellished with numbers and quotations to lend validity and an air of authority to Dr. C.N.B.'s opinion, depend on mischaracterization of his source document. This is itself evidence that Dr. C.N.B.'s opinion is nearly worthless. Dr. C.N.B.'s Reason (6) is that the veteran "does not have other risk factors for the development of GBM other than exposure to AO in service." Reason (6) hinges on the speculation offered by Dr. C.B. in his earlier reasons. As just explained, Dr. C.N.B.'s rationale for why AO is a risk factor is no more than sheer speculation supported by misrepresentations. As speculative medical opinion evidence cannot support a grant of service connection, all the more so reasons that rely on that speculation cannot support a grant of service connection. In short, Reason (6) amounts to a statement that the veteran has no risk factors for his brain cancer. For Reason (7) Dr. C.N.B. states that he noted that there were several articles in the claims file discussing sarcomas and agent orange and that "[i]t is well known that AO has a biological plausible mechanism for causing neoplasms and that AO induces several types f tumor cells lines (sarcomas and GBMs) is consistent with current medical knowledge." Dr. C.N.B.'s Reason (7) is more of the same. He disingenuously inserts assumptions that are without any stated support. He states that the articles in the claims file that discuss Agent Orange and sarcomas. This the Board does not dispute. He then states "it is well known that AO has a biologically plausible mechanism for causing neoplasms and therefore the fact that AO induces several types of tumor cell lines (sarcomas and GBMs) is consistent with current medical knowledge..." Dr. C.N.B. has inserted "GBMs" in his parenthetical, however, Dr. C.N.B. has pointed to nothing to justify his inclusion of GBM's in the parenthetical. To find that there is a relationship between a sarcoma, specifically soft tissue sarcomas, one need look no further than VA regulations. Dr. C.N.B.'s Reason (7) adds nothing to that fact. Even more damaging to the value of Reason (7) is the bulk of the articles to which Dr. C.N.B. refers to as associated with the claims file as supportive of a connection between the veteran's brain cancer and Agent Orange is supportive rather of a finding that there is no connection. The Board has reviewed those articles and finds that, as to specifics regarding astrocytoma, the material does not provide evidence favorable to the appellant's claim. While the treatise evidence does provide evidence that some cancers are associated with exposure to Agent Orange, the treatise evidence is lacking as to the specific type of cancer from which the veteran died, to be not probative of the disputed fact - whether the veteran's astrocytoma Grade III was related to exposure to Agent Orange. Reason (7), stripped of obfuscations, amounts to a statement that Agent Orange is accepted as causing come malignant tumors, therefore it follows that Agent Orange causes all malignant tumors. This is just another example of faulty reasoning. This logic is untenable because it amounts to an argument to place malignant tumors, regardless as to the type of cancer or its origin, on the list of diseases for which the presumption of service connection for exposure to herbicides applies. Finally, Dr. C.N.B. lists Reason (8) as his agreement with the opinions of Dr. R.A.F. and Dr. H.A.D. However, this is also disingenuous as is shown by his next paragraph. In that paragraph he states that he noted that several physicians in 2003/2004 opined about sarcomas and the veteran's symptoms during service. He reports that these opinions are not useful because the issue, as he defines it, is the broad concept of whether the veteran's tumor was caused by Agent Orange. Dr. C.N.B. states "I am in agreement with Dr. [E.D.M.] that this patient's GBM is likely not a form of sarcoma for the purposes of presumptive service connection. Here, Dr. C.N.B. undercuts the medical opinions of the physicians to which he asserts agreements. Reason (8) is simply incredible as it amounts to a statement that the rationale supporting a finding that the veteran's brain tumor was caused by exposure to Agent Orange does not matter, all that matters is the conclusion. In other words, even contradictory reasons used to support causation do not impact negatively on the ultimate conclusion that Agent Orange caused the veteran's brain tumor as long as everyone agrees that it did. Dr. C.N.B.'s opinion, at best, is highly speculative and of almost no probative value. His misstatement of data, selective quotations, deception, use of statements and data out of context, and reference to sources that, upon inspection, contradict his conclusion, is evidence that there is no reliable scientific or medical basis for a nexus between the herbicide agent found in Agent Orange and the cancer that caused the veteran's death. If there were, there would be no reason to resort to the unprofessional tactics employed by Dr. C.N.B. Thus, if anything, Dr. C.N.B.'s letter is evidence against the appellant's claim. Based on a review of his statements, the Board finds that the opinion of this doctor has no probative weight and the bases for his views are in serious question. In summary, the Board finds that the medical opinions provided by Dr. C.A. in April 2006 and in July 2003, the medical opinion provided by P.B. in August 2004, the June 1984 pathology report of Dr. E.D.M., are more probative of the type of cancer the veteran died from and of relationship, or lack thereof, of that cancer to exposure to herbicides during service or any other connection to service, than are the letters from Dr. R.A.F., Dr. H.A.D., Dr. C.N.B. As to the treatise evidence associated with the claims file, this evidence is not favorable to the appellant's claim because it provides no information linking the type of cancer suffered by the veteran to his exposure to herbicides or otherwise to his service. Finally, the preponderance of the evidence is against a finding that the veteran's tumor otherwise had onset during service, within one year of separation from service, or was directly caused by his service. The service medical records, the long period of time from separation from service to onset of symptoms of the veteran's cancer, and the medical opinion evidence unfavorable on this question outweighs the medical opinion evidence favorable to the appellant's claim on this issue. As to the appellant's own opinion in this matter, she has not demonstrated the requisite medical expertise to offer competent opinion evidence on so complex a matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Because the preponderance of the evidence is against a finding that the veteran died from a disease caused by or related to his service, the appellant's claim must be denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2007). Duties to notify and assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service- connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, although the notice provided did not address either the rating criteria or effective date provisions that are pertinent to the veteran's claim, such error was harmless given that service connection is being denied, and hence no rating or effective date will be assigned with respect to this claimed condition. In Kent v. Nicholson, 20 Vet. App. 1 (2006), the Court clarified VA's duty to notify in the context of claims to reopen. With respect to such claims, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. To satisfy this requirement, the Secretary is required to look at the bases for the denial in the prior decision and to provide the claimant with a notice letter that describes what evidence would be necessary to substantiate those elements required to establish service connection that were found insufficient in the previous denial. The Board reopened the appellant's claim in a November 2005 decision. As the purpose of the specialized notice required by Kent has been achieved, no prejudice can result to the appellant from the lack of notice as to the requirements necessary to reopen a previously denied claim. In the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, section 5103(a) notice must include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a predecisional adjudication of the claim prior to providing a section 5103(a)-compliant notice. Because service connection had not been established for any disability during the veteran's lifetime, the notice required in this case does not include notice regarding disabilities for which service connection had been established during the veteran's lifetime. That the veteran's death was caused by a malignant tumor of the brain is not a fact in dispute. Hence, the notice required amounts to notice as to what evidence is required to establish service connection for the disease that caused the veteran's death and a statement of VA's and the appellant's respective duties in obtaining that evidence. Here, the remaining VCAA duty to notify was satisfied by way of a letter sent to the veteran in May 2003 that fully addressed all three notice elements and was sent prior to the initial RO decision in this matter in July 2003. The letter informed the veteran of what evidence was required to substantiate service connection for the cause of the veteran's disease that caused his death and of the appellant's and VA's respective duties for obtaining evidence. Furthermore, the Board finds that any error in notice in this case is non-prejudicial to the appellant because she has overwhelmingly demonstrated actual knowledge of that which VCAA notice would have informed her. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. The Federal Circuit stated that requiring an appellant to demonstrate prejudice as a result of any notice error is inconsistent with the purposes of both the VCAA and VA's uniquely pro-claimant benefits system. Instead, the Federal Circuit held in Sanders that all VCAA notice errors are presumed prejudicial and require reversal unless VA can show that the error did not affect the essential fairness of the adjudication. To do this, VA must show that the purpose of the notice was not frustrated, such as by demonstrating: (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or (3) that a benefit could not have been awarded as a matter of law. Although not specifically discussed by the court, some other possible circumstances that could demonstrate that VA error did not prejudice the claimant include where the claimant has stated that he or she has no further evidence to submit, or where the record reflects that VA has obtained all relevant evidence. The appellant is represented by counsel. She has appealed this matter to the Court and has argued to the RO, the Board, and the Court the very point upon which this case turns - whether the veteran's fatal disease was caused by his service. The appellant has cited to regulations that govern this matter. She has demonstrated more knowledge as to the requirements to substantiate her claim and what evidence was lacking in this case than she would have been informed of in a completely content complying notice letter sent to her upon receipt of her current claim. VA has a duty to assist the appellant in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and obtaining a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Associated with the claims file are medical opinion letters from "R.T.F.", M.D., "H.A.D.", M.D., and "C.N.B.", M.D. Also associated with the claims file are terminal treatment records, including a pathology report signed by E.D.M., M.D. VA medical opinions were obtained in July 2003, August 2004, and April 2006. The medical evidence of record is sufficient for the Board to render a decision in this case. See 38 U.S.C.A. § 5103A; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER The appeal is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs