Citation Nr: 1127340 Decision Date: 07/22/11 Archive Date: 07/29/11 DOCKET NO. 06-38 664 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from March 1957 to March 1977. He died in April 2005. The appellant is his widow. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. FINDINGS OF FACT 1. The Veteran served in Vietnam and is presumed to have been exposed to herbicides during his service. 2. At the time of the Veteran's death, service connection was in effect for hypertension, rated as 20 percent disabling. 3. The Certificate of Death reflects that the Veteran died at the age of 70 in April 2005. The immediate cause of death was cancer. There were no significant conditions contributing to death. 4. The most probative evidence of record establishes that the Veteran's terminal cancer was colon cancer. 5. The Secretary of VA has not specifically determined that there is a positive association between herbicide exposure and colon cancer. 6. Colon cancer was not manifest during service nor within one year of separation; colon cancer is not attributable to service. 7. The Veteran's service-connected hypertension was not the immediate or underlying cause of the Veteran's death, and was not etiologically related to the cause of death; the Veteran's service-connected hypertension did not contribute substantially or materially to cause the Veteran's death and they was not of such severity that they resulted in debilitating effects and a general impairment of health to an extent that rendered the Veteran materially less capable of resisting the effects of other disease causing death. CONCLUSION OF LAW A disability incurred in or aggravated by service did not cause or contribute substantially or materially to the cause of death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 1310 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303. 3.304, 3.307, 3.309, 3.312 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) With respect to the appellant's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the appellant 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 appellant 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 Veteran is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). 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 U.S. Court of Appeals for Veterans Claims (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 Veteran 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. The Court issued certain directives pertinent to cases where the issue is service connection for the cause of a veteran's death in Hupp v. Nicholson, 21 Vet. App. 342 (2007). The Court held that there is no preliminary obligation on the part of VA to perform, what in essence would be, a predecisional adjudication of a claim prior to providing to the Veteran section 5103(a) notice. Although section 5103(a) does not require a "predecisional adjudication" of the evidence in each case, the notice must be responsive to the particular application submitted. See Kent v. Nicholson, 20 Vet. App. 1 (2006), at 9 ("The legislative interest underlying the VCAA notice requirement is the intent of Congress to provide Veterans a meaningful opportunity to participate in the adjudication of claims"). This means that there is a middle ground between a predecisional adjudication and boilerplate notice with regard to the amount of detail and degree of specificity VA must provide for section 5103(a)-compliant notice. The Court later stated that a more detailed notice potentially discourages a Veteran from submitting additional or corroborative notice, and is contrary to the VCAA's purpose. However, in DIC cases where a veteran was service-connected during his or her lifetime, the Court found that 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 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. In this case, the Veteran was service connected for hypertension during his lifetime. The VCAA notification did not specifically address this matter per Hupp. However, the appellant was provided pertinent information in the statement of the case. In addition, she and her representative have made specific contentions regarding the Veteran's service and his death, demonstrating her understanding that the evidence must establish that the Veteran's death is related to service. In the correspondence from the appellant and her representative, they made clear that the premise of the current claim is not that hypertension is etiologically related to death, but rather that the Veteran's inservice exposure to herbicides caused cancer which caused death. The appellant has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir., 2004). A July 2005 RO letter informed the appellant of all elements required by 38 C.F.R. § 3.159(b), as stated above. As the claim is being denied, no disability rating or effective date can be assigned, thus there is no prejudice under Dingess. Regarding the duty to assist, the Veteran's service treatment records and pertinent post-service medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. As discussed in greater detail below, an expert medical opinion has been obtained which is sufficient because it included a review of pertinent records and supporting rationale. See generally Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The records satisfy 38 C.F.R. § 3.326. In summary, the Board finds that "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances as to when a remand would not result in any significant benefit to the Veteran). Service Connection for the Cause of the Veteran's Death In order to establish service connection for the cause of the veteran's death, applicable law requires that the evidence show that a disability incurred in or aggravated by service either caused or contributed substantially or materially to death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. For a service-connected disability to constitute a contributory cause, it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. In order to constitute the principal cause of death the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. Id. There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4). Therefore, 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 the death or substantially or materially contributed to it. 38 U.S.C.A. § 1310. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In addition, cancer (malignant tumor) will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. VA law and regulations further provide that a chronic, tropical, or prisoner-of-war related disease, or a disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309 will be considered to have been incurred in or aggravated by service under the circumstances outlined in this section even though there is no evidence of such disease during the period of service. No condition other than the ones listed in 38 C.F.R. § 3.309(a) will be considered chronic. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116; 38 C.F.R. § 3.307(a). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 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 that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. If a veteran, who served in the Republic of Vietnam 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 U.S.C.A. § 1116, 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113; 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), type II diabetes, and chronic lymphocytic leukemia. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). 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. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449 (1996). Section 2 of the Agent Orange Act of 1991, Pub. L. 102-4 (Act), codified in pertinent part at 38 U.S.C.A. §§ 1116(b) and (c), provides that whenever the Secretary determines, based on sound medical and scientific evidence, that a positive association (i.e., the credible evidence for the association is equal to or outweighs the credible evidence against the association) exists between exposure of humans to an herbicide agent and a disease, the Secretary will publish regulations establishing presumptive service connection for that disease. If the Secretary determines that a presumption of service connection is not warranted, he is to publish a notice of that determination, including an explanation of the scientific basis for that determination. The Secretary's determination must be based on consideration of reports of the National Academy of Sciences (NAS) and all other sound medical and scientific information and analysis available to the Secretary. Although 38 U.S.C. § 1116 does not define "credible," it does instruct the Secretary to "take into consideration whether the results [of any study] are statistically significant, are capable of replication, and withstand peer review." Simply comparing the number of studies which report a positive relative risk to the number of studies which report a negative relative risk for a particular condition is not a valid method for determining whether the weight of evidence overall supports a finding that there is or is not a positive association between herbicide exposure and the subsequent development of the particular condition. Because of differences in statistical significance, confidence levels, control for confounding factors, bias, and other pertinent characteristics, some studies are clearly more credible than others, and the Secretary has given the more credible studies more weight in evaluating the overall weight of the evidence concerning specific diseases. Section 3 of the Act directs the Secretary of VA to seek to enter into an agreement with the NAS to review and summarize the scientific evidence concerning the association between exposure to herbicides used in the Republic of Vietnam and each disease suspected to be associated with such exposure. Claims based on Agent Orange exposure are unique in that entitlement, under the presumptions codified in 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307 and 3.309, is based on an analysis of scientific evidence. Section 3 of the Agent Orange Act of 1991 directed the Secretary of VA to seek to enter into an agreement with NAS to review and summarize the scientific evidence concerning the association between exposure to herbicides used in the Republic of Vietnam and each disease suspected to be associated with such exposure. The Secretary determined, based on sound medical and scientific evidence, that a positive association (i.e., where the credible evidence for the association was equal to or outweighed the credible evidence against the association) existed between exposure to an herbicide agent and the disorders listed in the statute. See 64 Fed. Reg. 59232, 592233 (Nov. 2, 1999). In addition, the Secretary has published a list of specific conditions for which a presumption of service connection based on exposure to herbicides used in Vietnam during the Vietnam era is not warranted. These include hepatobiliary cancers, nasal/nasopharyngeal cancer, bone cancer, female reproductive cancers, breast cancer, renal cancer, testicular cancer, leukemia, abnormal sperm parameters and infertility, cognitive and neuropsychiatric disorders, motor/coordination dysfunction, chronic peripheral nervous system disorders, metabolic and digestive disorders, immune system disorders, circulatory disorders, respiratory disorders (other than certain respiratory cancers), skin cancer, gastrointestinal tumors, bladder cancer, brain tumors, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 64 Fed. Reg. 59232-59243 (1999). Recent action concerning herbicide-related disability has been undertaken by VA. On October 13, 2009, in accordance with authority provided in 38 U.S.C. § 1116, the Secretary of Veterans Affairs announced his decision to establish presumptions of service connection, based upon exposure to herbicides within the Republic of Vietnam during the Vietnam era, for three new conditions: ischemic heart disease, Parkinson's disease, and B cell leukemias. On August 31, 2010, VA published a final rule amending 38 C.F.R. § 3.309(e) to add hairy cell leukemia and other chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease to the list of diseases associated with exposure to certain herbicide agents. 75 Fed. Reg. 53202. The term ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina. VA regulation also provides that, with chronic disease shown as such in service (or within an applicable presumptive period under section 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of an evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection, the evidence must show: (1) the existence of a present disability; (2) inservice incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during the service." Shedden v. Principi, 381 F. 3d 1163, 1166-67 (Fed. Cir. 2004). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). The Veteran served in Vietnam and had presumed exposure to herbicides agents during his in-country service in Vietnam. He was service connected for hypertension during his lifetime, rated as 20 percent disabling. The Veteran died in April 2005 at the age of 70 years. His Certificate of Death indicates that the only cause of death was "cancer" and no autopsy was performed. There were no significant conditions contributing to death. Prior to his death, the Veteran was hospitalized for treatment of the terminal cancer. The hospitalization records reflect that he had cancerous lesions in his colon, liver, and lung. The cancer was noted to be metastatic in nature. The discharge summary indicated that it was "possibly adenocarcinoma of the cecum." Another discharge summary stated that he had malignant neoplasia of the ascending colon, secondary malignant neoplasia on the liver, and secondary malignant neoplasia of the lung. An abdominal ultrasound showed multiple hepatic masses, possible related to primary or metastatic neoplastic disease. A computerized tomography (CT) of the chest showed multiple lung neoplasms, the largest in the right ling base, with multiple small neoplasms also present. The Veteran's treating physician, Anthony J. Fava, M.D., indicated in a February 2005 letter, received in March 2006, that he had treated the Veteran from November 2004 to April 2004. He stated that the Veteran had multiple hepatic masses which were metastatic secondary to a metastatic neoplastic disease identified only as "cancer" and that there were also multiple lung neoplasms which were "cancer." Thereafter, the Board referred this case for a VA medical expert opinion since the nature of the terminal cancer was unclear. The Board requested an opinion on the following question: Is it at least as likely as not (50 percent or greater probability) that the Veteran's lung cancer was the primary site of his cancer? Please provide a complete rationale for your opinion, citing the objective medical findings leading to the conclusion. A discussion of the facts and the medical principles involved will be of considerable assistance. In March 2011, the Head of a VA Section of Hematology and Oncology submitted an opinion. He stated that the Veteran died in April 2005. Prior to his death, he was hospitalized and underwent various studies, including an MRI of the chest and abdomen, an abdominal ultrasound, and a chest CT. The findings were of extensive metastatic cancer involving near replacement of the liver with tumor, extensive pulmonary metastases, and extensive Mediastinal nodal metastases. He underwent an upper endoscopy (EGD) and colonoscopy the day before he died. No malignancy was detected on the upper endoscopy. A circumferential tumor was seen the ascending colon, just distal to the cecum. A biopsy was performed which revealed adenocarcinoma, moderately differentiated. The pathology report was generated at another facility and was dated the date of the Veteran's death, and was finalized the following day. The VA medical expert indicated that the Veteran expired the day after the colonoscopy from multi-organ failure, likely due to septic shock, per hospital records. He stated that in his professional opinion, the underlying illness that led to the Veteran's death was advanced metastatic colon cancer. He stated that there was no objective data to support a primary diagnosis of any other malignancy. The doctor concluded that it was not as likely as not that the Veteran's lung (lung cancer) was the primary site of the cancer. In sum, the VA medical expert indicated that the Veteran had colon cancer which was the cause of death. The Board attaches the most probative value to this medical expert opinion, as it is well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion); see also Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is factually accurate, fully articulated, and has sound reasoning for the conclusion). The medical expert is a specialist in oncology and thoroughly reviewed the record. Thus, the Board accepts that the Veteran died as a result of colon cancer. A review of the service treatment records reflects no complaints, findings, treatment, or diagnosis of colon cancer nor does the record show that it was manifest in the initial post-service year. Rather, the record shows that it developed decades after the Veteran was separated from service and is unrelated thereto. Unfortunately, this cancer metastasized to multiple areas and caused the Veteran's death. The appellant asserts that the Veteran developed cancer due to inservice herbicide exposure. The appellant's assertions are simply not probative since that matter requires medical expertise which she does not possess. The Federal Circuit has recognized that in some cases, lay testimony falls short in proving an issue that requires medical knowledge. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010). While the appellant is competent to provide an observation, the question of an exact diagnosis of a type of cancer or an etiological relationship between the cancer and service is a matter requiring medical expertise that the Veteran has not been shown to possess. Compare Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). The Veteran was exposed to herbicides; however, the Secretary of VA has not specifically determined that there is a positive association between herbicide exposure and colon cancer. There is no conflicting competent evidence in that regard. Thus, colon cancer is not a disability for which herbicide presumptive service connection can be established. Further, as noted, there were no inservice manifestations or diagnosis of colon cancer, no manifestations in the initial post-service year, and no competent evidence suggestive any etiological connection between the diagnosis made decades after discharge and the Veteran's service. Thus, there is no etiological nexus between the Veteran's cause of death from colon cancer and service. The Board recognizes that lung cancer is a presumptive cancer for herbicide exposure, but the medical expert explained that the primary site of the Veteran's cancer was the colon. As noted, the Veteran's service connected hypertension disability was rated as 20 percent disabling. However, there is no competent evidence suggestive that hypertension played any role in the Veteran's death. Rather, the medical expert opinion explained at length that the colon cancer was the sole cause of death. The Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record. Hensley v. Brown, 5 Vet. App. 155 (1993). In considering this matter on appeal the Board is required to base its decisions on the most probative medical evidence which has been obtained as noted above, rather than rely upon its own unsubstantiated medical opinions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Likewise, the Board attaches greater probative weight to the findings of skilled, unbiased professional than to the statements of the appellant and her representative. The appellant is sincere in her contentions, but they are not probative evidence and are not supported by the expert medical opinion. Thus, the Board concludes that the Veteran's service-connected hypertension was not the immediate or underlying cause of the Veteran's death, and was not etiologically related to the cause of death. Furthermore, colon cancer was not manifest during service or within one year of separation and there is no competent evidence of record relating the Veteran's colon cancer to his service. The Veteran's service-connected hypertension did not contribute substantially or materially to cause his death and it was not of such severity that it resulted in debilitating effects and a general impairment of health to an extent that rendered him materially less capable of resisting the effects of other disease causing death. The Board concludes that the preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49 53 (1990). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board Veterans' Appeals Department of Veterans Affairs