Citation Nr: 0904584 Decision Date: 02/09/09 Archive Date: 02/13/09 DOCKET NO. 03-10 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUE Entitlement to service connection for carcinoma in situ of the exocervix. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The veteran had multiple periods of inactive duty for training from June 1990 to March 1995; multiple periods of active duty for training from February 1991 to March 1995; and specifically, active duty from July 1990 to October 1990 and from January 1992 to February 1993. This matter comes before the Board of Veterans' Appeals (Board) from a July 2002 rating decision by the Winston- Salem, North Carolina Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the veteran service connection for carcinoma in situ of the exocervix. In July 2004, the veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. In December 2004 and April 2006, the Board remanded the veteran's claim to the RO via the Appeals Management Center (AMC) for additional development. Thereafter, in July 2008, the Board sought an independent medical opinion (IME) regarding the matter on appeal. A review of the record reveals additional evidence was associated with the file subsequent to the issuance of the June 2007 supplemental statement of the case. The Board finds, however, that this additional evidence is either cumulative of the existing record or is not pertinent to the issue on appeal. Therefore, an additional remand for agency of original jurisdiction consideration is not required. See 38 C.F.R. § 20.1304 (2008). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. Competent and persuasive evidence of record does not demonstrate that carcinoma in situ of the exocervix was manifested during active service, was manifested within the first post-service year, or was developed as a result of an established event, injury, or disease during active service. CONCLUSION OF LAW Carcinoma in situ of the exocervix was not incurred in or aggravated by during active military service, nor may incurrence of a malignant tumor be presumed. 38 U.S.C.A. §§ 1101, 1110, 1111, 1112, 1113, 1116, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the veteran filed her service connection claim in January 2002. Thereafter, she was notified of the provisions of the VCAA by correspondence dated in March 2002, February 2005, and July 2006. These letters notified the veteran of VA's responsibilities in obtaining information to assist the veteran in completing her claim, identified the veteran's duties in obtaining information and evidence to substantiate her claim, and provided other pertinent information regarding VCAA. Thereafter, the claim was reviewed and a supplemental statement of the case (SSOC) was issued in June 2007. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 07-7130 (Fed. Cir. September 17, 2007). The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, removing the sentence in subsection (b)(1) stating that VA will request the claimant provide any evidence in the claimant's possession that pertains to the claim. Subsection (b)(3) was also added and notes that no duty to provide § 5103(a) notice arises "[u]pon receipt of a Notice of Disagreement" or when "as a matter of law, entitlement to the benefit claimed cannot be established." See 73 Fed. Reg. 23,353-23,356 (Apr. 30, 2008). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was provided in June 2006. The veteran has been made aware of the information and evidence necessary to substantiate her claim and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist her in obtaining evidence necessary to substantiate her claim during the course of this appeal. Her service treatment records, service personnel records, and all relevant VA and private treatment records pertaining to her claim have been obtained and associated with her claims file. The veteran has also been provided with a VA medical examination as well as an independent medical opinion to assess the nature and etiology of her claimed gynecological disability. Furthermore, the veteran has not identified any additional, relevant evidence that has not otherwise been requested or obtained. The veteran has been notified of the evidence and information necessary to substantiate her claim, and she has been notified of VA's efforts to assist her. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating her claim. Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. See 38 C.F.R. § 3.303(d). Service connection shall be granted to a veteran if the veteran served 90 days or more during a war period or after December 31, 1946 or had peacetime service on or after January 1, 1947, and a malignant tumor, although not otherwise established as incurred in or aggravated by service, is manifested to a compensable degree within one year following the requisite service. See 38 C.F.R. §§ 3.307, 3.309 (2008). As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. See 38 C.F.R. § 3.102 (2008). Factual Background Service treatment records are negative for treatment for carcinoma in situ of the cervix or cervical cancer. A physical examination performed on entrance to active duty in July 1990 included a vaginal pelvic examination which was normal. In association with the physical examination, the veteran also provided a Report of Medical History in July 1990, in which she indicated that she had been previously treated for irregular periods and had experienced a change in her menstrual cycle. No further explanation was provided. The record reveals that the veteran was hospitalized and treated for pelvic inflammatory disease (PID) in May 1992. A physical examination performed while on active duty in November 1992 included a vaginal pelvic examination which was normal. The record reflects that the veteran received gynecological care from private physicians during her period of active duty service. Private medical records from D.B., M.D. show that in July 1992, the veteran was diagnosed with anemia, etiology uncertain during a breast and pelvic examination. Additional private treatment records show that the veteran received gynecological care from M.A.C., M.D. from 1992 to 1997, to include during her period of active duty service. A July 1992 Pap smear was class II; atypical, without evidence of malignancy or squamous atypia; possibly dysplastic, of indeterminate significance. A December 1992 treatment record noted that the veteran was hospitalized in May 1992 for dehydration and has a diagnosis of PID. A repeat Pap smear in December 1992 was abnormal, class III. A cryosurgery was performed and two biopsies were taken. The December 1992 pathology report from Raleigh Pathology noted that a cervical biopsy showed slight to moderate nonkeratinizing dysplasia with condylomatous atypia. A December 1992 colposcopy examination showed mild dysplasia and possible HPV. A December 1992 report listed an impression of normal pelvic ultrasound. A May 1993 Pap smear from Raleigh Pathology showed a high grade squamous intraepithelial lesion; moderate to severe dysplasia; and cellular changes associated with human papilloma virus (HPV). A May 1993 pathology report from the cervical biopsy identified condylomatous atypia and severe dysplasia (CIN 3). Endocervical currettings revealed endocervical columnar epithelium negative for dysplasia and condyloma. A June 1993 operative report from Wake Medical Center reflects that the veteran underwent laser vaporization of the exocervix and shows pre-operative and post-operative diagnoses of carcinoma in situ of the cervix. A November 1993 Pap smear from Raleigh Pathology showed benign cellular changes, without atypical or malignant cells. A February 1994 operative report from Wake Medical Center reflects that the veteran underwent a diagnostic laparoscopy to determine the origin of her chronic pelvic pain, status post laser vaporization (ablation) of the cervix. The test showed normal fallopian tubes, ovaries and uterus and the postoperative diagnosis was normal pelvis. Pap smears dated in June 1994, October 1994, January 1995, and June 1995 from Raleigh Pathology showed only benign cellular changes, without atypical or malignant cells present; Class I. A clinical record dated in October 1995 from F.C.H., M.D., shows that after complaints of left pelvic pain, the appellant was diagnosed with a left ovarian cyst. An October 1995 report from Wake Radiology revealed that abdominal and endovaginal pelvic ultrasounds were negative. An October 1995 transabdominal and endovaginal pelvic ultrasound examination demonstrated a small right ovarian follicle. An April 1996 Pap smear from Raleigh Pathology revealed squamous cellular changes, associated with a benign reactive/reparative process; Class I. Emergency room records dated in June 1996 from Rex Healthcare noted a medical history of left ovarian cyst and noted complaints of left lower quadrant pain. The diagnosis was ruptured ovarian cyst. A March 1997 Pap smear was within normal limits, with no atypical or malignant cells present. During an August 1997 VA psychiatric examination, the veteran complained of pelvic pain attacks one or two times a month. In a December 2001 VA treatment note, the veteran indicated that she had a private October 2001 Pap smear and routine gynecological examination with normal findings. A January 2002 from Wake Radiology transabdominal and endovaginal pelvic ultrasound examination revealed normal pelvic findings. Private treatment records dated from September to November 2002 from Cary Obstetrics and Gynecology reflect complaints of left lower quadrant pain and chronic pelvic pain. An October 2002 cytopathology report from Rex Healthcare revealed findings negative for intraepithelial lesion or malignancy. The veteran underwent a second laparoscopy and bilateral tubal ligation in November 2002 at Western Wake Medical Center. The procedure revealed normal uterus, tubes, and ovaries bilaterally. She did have an adhesion of the omentum to the anterior peritoneum from the prior laparoscopic surgery. No other abnormalities were noted. In a May 2003 letter, G.K.S., M.D. noted that the veteran had a long history of significant pelvic pain. The physician detailed that his letter was to clarify the relationship of some of the veteran's recurrent problems to her prior in- service diagnosis of PID. It was noted that PID has long been known to be closely associated to abnormal Pap smears through the mechanism of the human papilloma virus and to cause significant pelvic adhesions which can result in pelvic pain for prolonged periods of time. The physician indicated that the veteran has had a persistent, significant chronic pelvic pain over the last several years. The physician indicated that a prior laparoscopy showed some residual adhesive disease in the pelvis, the etiology of which may in fact be from PID. During her July 2004 hearing, the veteran complained of breakthrough bleeding, abnormal menstrual disturbances, back pain, leg pain, cramping, pelvic pain, vomiting, diarrhea, and PTSD. She also submitted medical treatise information concerning risk factors, symptoms, and treatment options of cervical cancer as well as PID and HPV. In a written opinion dated in August 2004, C. N. B., M.D., a neuro-radiologist, indicated that he had reviewed the appellant's service medical records, post-service medical records, imaging reports, other medical opinions, medical literature; and also conducted a patient interview. He opined that the appellant's lower abdominal symptoms of bloating, pain, irregular bleeding/periods/infections and diarrhea/constipation which have all been occurring since 1992 are all likely due to her service-acquired PID or its sequela and/or secondary to her 1994 laparoscopy. He further wrote that without a current cervical evaluation her [the appellant's] biopsy-proven "...mild to moderate dysplasia with condylomatous atypia...HPV... carcinoma in situ..." could be contributing to her current symptomatology. He stated that his opinion was based upon these specific reasons: 1) the veteran currently has PID; 2) PID is well known to cause pelvic pain and complications with adjacent organs and many of the appellant's symptoms correspond to complications of this disease; 3) she had a laparoscope in 1994, which is well known to cause pelvic inflammation and scarring and bowel and/or bladder complaints; 4) the literature supports associations between PID and other pelvic complications; and 5) the medical record does not include other diagnoses to account for her symptoms. In a November 2004 VA treatment note, the veteran indicated that she had a private April 2004 Pap smear and routine gynecological examination with normal findings. The veteran underwent a VA examination in March 2005, at which time all of the claim files were reviewed. The VA obstetrician/gynecologist discussed the veteran's detailed past obstetric history. A 1992 Pap smear was class II with repeat December 1992 Pap smear revealing abnormal findings. Thereafter, she underwent colposcopy and biopsies. A pathology report showed condylomatous atypia with slight to moderate dysplasia. This was treated with cryosurgery therapy. Follow-up May 1993 pathology report revealed class III Pap smear consistent with severe dysplasia. She underwent repeat colposcopy and biopsies with the pathology report showing condylomatous atypica and severe dysplasia of the cervix. Endocervical currettings were also noted to be negative. She underwent laser conization in June 1993. The examiner pointed out that while the pathology diagnosis was severe dysplasia-her gynecological surgeon used the term "carcinoma in situ of the cervix" as an operative diagnosis at the time of her laser therapy. It was further noted by the VA physician that the veteran had undergone numerous normal Pap smears since then. The veteran also reported a history of chronic problems of pelvic pain, abdominal bloating, especially in the left lower quadrant, and irregular vaginal bleeding. She was noted to have extensive workups for these symptoms including numerous ultrasounds and other diagnostic tests. She also underwent a diagnostic laparoscopy in 1994 that revealed completely normal pelvic organs. She again underwent a diagnostic laparoscopy in November 2002 and also had a tubal ligation carried out at that time. The only finding being that the operative procedure was one band of adhesion from omentum to anterior abdominal wall, which was thought to be from her previous laparoscopy. This was easily lysed. The uterus, tubes, and ovaries were all reported otherwise as completely normal. The examiner further noted that while there had been a question in the past of a diagnosis of pelvic inflammatory disease, both of her laparoscopic examinations are noted to have been completely unremarkable. The veteran indicated that she had a Pap smear two weeks earlier which was normal. In his March 2005 examination report, the VA examiner noted that he had reviewed the veteran's claims file, interviewed the veteran, and indicated that a pelvic examination was denied by the veteran due to her prior psychologic history and aversion to male gynecologists. However, his diagnoses included: history of severe dysplasia of the cervix, treated with laser conization with long-term negative follow-up; and history of recurrent pelvic pain, irregular bleeding, and associated pelvic symptoms with two completely negative laparoscopic examinations. In response to specific questioning as to whether carcinoma in situ in the cervix is a malignancy, the examiner emphasized that most gynecologists and pathologists still make a distinction between "dysplasia of the cervix," which is a pre-cancerous lesion and "carcinoma in situ in the cervix," which is the very early stage of cervical carcinoma/cancer. In most cases the diagnosis and treatment may be altered based upon the distinction between the two, which may be subtle in some cases; but it is still a widely accepted approach in terms of diagnosis and treatment. The gynecologist also questioned the qualifications of the neuro-radiologist who rendered the August 2004 opinion to offer such an opinion. In a May 2005 VA treatment note, the veteran indicated that she had a private February 2005 Pap smear and routine gynecological examination with normal findings. In an additional statement dated in July 2005, C. N. B., M.D., indicated that he had reviewed the VA examiner's March 2005 report and did not see anything to make him change his previous opinion. In an April 2006 statement, a Chief in the Personal Affairs/Line of Duty Branch from the Department of the Army determined that the veteran acquired PID and HPV due to a 1989 sexual assault while attending Reserve Officer Training Camp and that this subsequently placed her in a very high risk of acquiring cervical dysplasia and cervical cancer. The veteran was found to be in the line of duty for PID and HPV. The Chief indicated in her statement that she had not received any communication from the Office of the Surgeon General, and that she had read medical research material and arrived at the decision based on her review. It should be noted that the Chief is a lay person and not a medical authority. In an April 2007 VA treatment note, the veteran indicated that she had a private December 2006 Pap smear and routine gynecological examination with normal findings and no evidence of malignancy. In July 2008, the Board sought an independent medical opinion (IME) to answer the following inquiries: 1) Is there any evidence that the veteran had carcinoma in situ of the exocervix during service or within one year thereafter? 2) If the response is negative, is there evidence that the veteran had carcinoma in situ of the exocervix at any time after service which, based on the evidence of record can be related to service based on continuity of symptomatology? and 3) If it is determined that the veteran had carcinoma in situ of the exocervix which can be related to service, does she have a present identifiable disability as a result of that cancer, and if so, what is the disability? Thereafter, the Board obtained an August 2008 opinion from an Associate Professor in the Department of Obstetrics and Gynecology at the University of Alabama-Birmingham School of Medicine. This physician made findings based on his review of the record but did not examine the veteran. In his conclusions, he indicated that there was no evidence that the veteran had carcinoma in situ of the exocervix during service or within one year thereafter. The physician noted that while the 1993 physician's operative note used the preoperative and postoperative diagnosis of carcinoma in situ, the supporting pathology reports do not support that assertion. It was further noted that the May 1993 Pap smear revealed moderate to severe dysplasia and the subsequent May 1993 colposcopic biopsies revealed severe dysplasia and condylomatous atypia. However, the pathologist did not describe any evidence of carcinoma in situ. The physician then detailed that laser conization of the cervix does not result in a pathologic specimen for evaluation and that all subsequent cervical cytology (Pap smears) have been normal. The physician further indicated that there was no evidence that the veteran had carcinoma in situ of the exocervix at any time after service that can be related to service based on continuity of symptomatology. It was noted that available records described normal cervical cytology from October 21, 1993 to September 2002. Finally, the physician clearly opined that the veteran has no pathologic evidence of carcinoma in situ. Analysis In this case, the Board notes that the record does not provide a basis for establishing service connection for the claimed disability of carcinoma in situ of the exocervix. Service treatment records show that the veteran was treated for PID and cervical dysplasia during active service. Post- service treatment records reflect continued complaints of chronic pelvic pain and an isolated finding of adhesion of the omentum to the anterior peritoneum from the prior laparoscopic surgery. Extensive post-service testing has been conducted due to the veteran's reported problems with chronic pelvic pain, including cervical cytology, pathology, laparoscopies, and ultrasounds, and revealed essentially normal findings. The May 2003 private gynecologist statement and the August 2004 private neuro-radiologist opinion note findings of PID and residual adhesive disease in the pelvis. The May 2003 statement did not address the issue before the Board: entitlement to service connection for carcinoma in situ of the exocervix, but instead addressed the veteran's complaints of pelvic pain and pelvic adhesions. Likewise, the August 2004 and July 2005 medical statements of C.N.B., M.D. also did not address the issue before the Board. In his statements, that physician indicated that the PID "could" be contributing to the veteran's current symptomatology, without specifically identifying carcinoma in situ of the exocervix; in fact, he concluded his August 2004 statement this way, "It is my opinion that this patient's lower abdominal symptoms of bloating, pain, irregular bleeding/periods/infections, diarrhea/constipation which have all be occurring since 1992 are likely due to her service acquired PID or its sequella and/or secondary to her 1994 laproscope." This conclusion does not address the issue before the Board. The Board finds that the conclusions reached by these private treatment providers do not establish whether the veteran has suffered from the claimed disability of carcinoma in situ of the exocervix during or at any time after service. Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Consequently, this evidence is insufficient to show that the veteran suffers her claimed disability of carcinoma in situ of the exocervix as a result of her active military service. By comparison, the Board accords great probative value to the March 2005 VA examiner opinion and August 2008 IME physician, and finds them to be dispositive of the question of whether the veteran, in fact, suffers from the claimed disability of carcinoma in situ of the exocervix. The Board recognizes that a June 1993 operative report from Wake Medical Center clearly reflects pre-operative and post-operative diagnoses of carcinoma in situ of the cervix. However, the March 2005 and August 2008 medical opinions were prepared by physicians with a specialty in gynecology and provided consistent and detailed findings to support the conclusion that the veteran did not have carcinoma in situ of the exocervix at any time during or after service. Further, the March 2005 VA examiner opinion and August 2008 IME specialist each provided comprehensive findings after reviewing the extensive service and post-service records, to include the private physician opinions discussed above. Therefore, the Board finds these medical opinions to be more persuasive than the opinions furnished by the private physicians on behalf of the veteran. In this case, the Board finds that the most persuasive medical evidence that specifically addresses the question of whether the veteran has carcinoma in situ of the exocervix weighs against the claim. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). In connection with the claim, the Board also has considered the assertions the veteran and her representative have advanced on appeal in multiple written statements as well as during her July 2004 hearing. However, the veteran cannot establish a service connection claim on the basis of her assertions, alone. While the Board does not doubt the sincerity of the veteran's belief that her claimed gynecological disability of carcinoma in situ of the exocervix is a result of events during active military service, this claim turns on medical matters-the diagnosis of a current disability and the relationship between current disability and service. Questions of medical diagnosis and causation are within the province of medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As a layperson without the appropriate medical training or expertise, the veteran simply is not competent to render a probative (i.e., persuasive) opinion on such a medical matter. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, her assertions in this regard simply do not constitute persuasive evidence in support of the claim for service connection. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, the Court has held that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Here, the treatise evidence which has been submitted by the veteran is general in nature and does not specifically relate to the facts and circumstances surrounding her particular case. The Board has determined that competent and persuasive medical evidence indicates that the veteran does not have carcinoma in situ of the exocervix. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110. Hence, in the absence of proof of carcinoma in situ of the exocervix (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 143-144 (1992). For the foregoing reasons, the claim for service connection for carcinoma in situ of the exocervix must be denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990). ORDER Entitlement to service connection for carcinoma in situ of the exocervix is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs