Citation Nr: 1306795 Decision Date: 02/27/13 Archive Date: 03/01/13 DOCKET NO. 07-05 719 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESSES AT HEARINGS ON APPEAL The appellant and Dr. H. Adams ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty from June 1962 to November 1984. He died in October 2004. The appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The appellant testified at a Decision Review Officer (DRO) hearing in May 2007, and at a Board hearing before the undersigned Veterans Law Judge in September 2009. Transcripts of both hearings are associated with the claims folder. In December 2009, June 2011, and June 2012, the Board remanded the case for additional development. The Board finds that the Appeals Management Center (AMC) has complied with the remand instructions, and that neither the appellant nor her representative has contended otherwise; therefore, it may proceed with its review of this appeal. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The appellant submitted a VA Form 9 in February 2007. She attached a statement authored by Dr. Adams, which raised the issue of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for the cause of the Veteran's death. Subsequently, during the May 2007 DRO hearing, Dr. Adams provided testimony regarding the appellant's claim for benefits under 38 U.S.C.A. § 1151. It is "well-established judicial doctrine that any statutory tribunal must ensure that it has jurisdiction over each case before adjudicating the merits, that a potential jurisdictional defect may be raised by the court or tribunal, sua sponte or by any party, at any stage in the proceedings, and, once apparent, must be adjudicated." Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Also, in Alleman v. Principi, 16 Vet. App. 253 (2002), aff'd by 349 F.3d 1368 (Fed. Cir. 2003), the Court stated that a Veteran who has been awarded benefits under 38 U.S.C. § 1151 is not considered to have been awarded service connection for the purpose of all ancillary benefits. 16 Vet. App. at 256. The Court went to great lengths to explain just how these types of claims (1151 versus service connection) were distinguishable from one another. The Board finds that the issue of entitlement to compensation under the provisions of 38 U.S.C.A. § 1151 for the cause of the Veteran's death has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran died in October 2004; the cause of the Veteran's death was squamous cell carcinoma. Bilateral pulmonary embolism due to post-operative complications from thoracic spine decompression surgery performed on August 30, 2004 was listed as a significant condition that contributed to the Veteran's death, but did not result in the underlying cause of death. 2. At the time of his death, the Veteran was service connected for left ear hearing loss, rated as noncompensable; residuals, status post undisplaced fracture of the distal 5th metacarpal of the right hand, rated as noncompensable; and residual scar, status post ganglion cyst removal, left wrist, rated as noncompensable. 3. The Veteran's squamous cell carcinoma with metastasis was first shown many years after service and is unrelated to any exposure, disease, or other incident in service. 4. The Veteran's service-connected disabilities did not cause his death or contribute materially or substantially to the cause of his death. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 1310, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative 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). The VCAA notice 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the context of a claim for Dependency Indemnity and Compensation (DIC) benefits based on service connection for the cause of a veteran's death, VCAA notice must also include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his 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 (2007). Here, however, the duty to provide notice relating to the appellant's claim for service connection for the cause of the Veteran's death was not fully satisfied pursuant to Hupp prior to the initial unfavorable decision by the RO. The Board notes that the initial notice provided in this case was issued prior to the decision in Hupp. As such, it does not take the form prescribed in that case. Nevertheless, lack of harm may be shown (1) when any defect was cured by actual knowledge on the part of the claimant; (2) when a reasonable person could be expected to understand from the notice what was needed; or (3) when a benefit could not have been awarded as a matter of law. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board finds that the appellant has shown actual knowledge of how to substantiate her claim. Statements, testimony, and legal briefs submitted by the appellant and her representative reflect knowledge of the disabilities for which the Veteran was service connected for during his lifetime. They have contended that the cause of the Veteran's death is attributable to several factors related to his active military service, to include in-service exposure to herbicides. Additionally, the appellant obtained a private medical opinion in an attempt to demonstrate that relationship. Accordingly, any failure to provide Hupp compliant notice does not prevent adjudication by the Board. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). The Board also finds that the January 2005 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In that letter, the appellant was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Moreover, VA has complied with its duty to assist the appellant in the development of her claim. VA has obtained service treatment records (STRs), private treatment records, and other federal records. She was provided with the opportunity to give testimony before the Board. No VA medical records were identified by the appellant. The Board notes that the Veteran applied for disability benefits from the Social Security Administration (SSA) shortly before his death. However, it appears that the Veteran died before a decision was issued. A pertinent VA opinion with respect to the issue on appeal was obtained in October 2011. See 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As discussed below, the VA opinion obtained in this case is adequate, as it is predicated on consideration of service records and post-service private records and provides a rationale for the conclusion that the Veteran's death was not caused by his service. Thus, the Board finds that VA's duty to assist with respect to obtaining a VA opinion concerning this issue of entitlement to service connection for the cause of the Veteran's death has been met. See 38 C.F.R. § 3.159(c)(4). In addition, there was substantial compliance with the December 2009, June 2011, and June 2012 remand directives. Specifically, the Board directed the AOJ to obtain additional relevant private treatment records, to include records associated with the Veteran's initial cancer diagnosis; records that Dr. Adams relied on in forming his opinion; records that the appellant referenced in her May 2006 Notice of Disagreement (NOD); and additional treatment records from the San Diego VAMC. In a January 2010 letter, the AMC requested names, addresses, and dates of treatment of all VA and private healthcare providers. It also requested treatment records from Dr. Adams. In a letter received later that month, the appellant indicated that Dr. Adams had relied on the Veteran's "medical records." In a June 2011 letter, the AMC requested records the appellant had relied on in preparing her NOD. No response was received. The AMC obtained additional treatment records from several private providers. The Board notes that two attempts to obtain additional treatment records from the San Diego VAMC resulted in duplicate copies of evidence already of record. In view of the foregoing, the Board concludes that further efforts to locate these records would be futile. Finally, as instructed, an adequate VA medical opinion as to the Veteran's cause of death was obtained in October 2011. 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. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). II. Analysis 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. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Generally, to prevail on a claim of service connection on the merits, there must be medical evidence of (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Certain VA benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C.A. § 1310; 38 C.F.R. §§ 3.5, 3.312 (2012). In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312(a). For a service-connected disability to be the principal cause of death, it must singly or with some other condition be the immediate or underlying cause of death or be etiologically related. 38 C.F.R. § 3.312(b). For a service-connected disability to constitute a contributory cause it must contribute substantially or materially; it is not sufficient to show that it casually shared in producing death; rather, it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c). If a veteran was exposed to an herbicide agent during active military, naval, or air service, respiratory cancers involving the lung, bronchus, larynx or trachea shall be service connected, even though there is no record of such disease during service. 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) must have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(6)(ii). A veteran may establish exposure to herbicides on a factual basis, or exposure may be presumed if the Veteran served in Vietnam between January 9, 1962, and May 7, 1975. 38 C.F.R. § 3.307. When all the evidence is assembled, 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 a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appellant contends that the Veteran's cancer was the result of numerous factors related to his military service, to include unresolved chronic pain. She also contends that the Veteran's squamous cell cancer was caused by exposure to herbicides, mold, and/or other toxic substances. Specifically, she maintains that the Veteran was exposed to herbicides while serving in Vietnam and as a result of his duties as a radioman in support of Special Operations. She also maintains that the Veteran was exposed to toxic substances, to include mold, while working as a civilian for the Department of the Navy at the Marine Corps Air Station in Miramar, the Naval Base Coronado in North Island, and the Naval Air Weapons Station in China Lake. See May 2006 Notice of Disagreement (NOD). The Veteran died in October 2004. The certificate of death lists the immediate cause as squamous cell cancer of the tonsil with metastasis to thoracic spine. The certificate of death notes that the interval between the onset of cancer and death was "months." Bilateral pulmonary embolisms due to post-operative complications from thoracic spine decompression surgery performed on August 30, 2004, were listed as a significant condition that contributed to the Veteran's death, but did not result in the underlying cause of death. Service department documents establish that the Veteran served in the Republic of Vietnam sometime between 1965 and 1971. Consequently, the Veteran may be presumed to have been exposed to herbicides during service. See 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Nevertheless, in order for presumptive service connection to be warranted under these provisions, the claimed disease must be one of the enumerated diseases listed in 38 C.F.R. § 3.309(e). The Board finds that the Veteran is not entitled to service connection based on that presumption because squamous cell carcinoma of the tonsil is not a recognized enumerated presumptive disease set forth in 38 C.F.R. § 3.309(e). As set forth above, respiratory cancers involving the lung, bronchus, larynx or trachea are diseases for purposes of presumptive service connection based upon herbicide exposure in the Republic of Vietnam. The medical evidence clearly shows, however, that the Veteran's cancer originated in his tonsil, which has not been included as part of the respiratory system for presumptive service connection purposes. Furthermore, the Secretary of VA, based upon the findings of the National Academy of Sciences, has specifically found that presumptive service connection is not warranted for cancers of the oral cavity (including lips and tongue). See Notice, 75 Fed. Reg. 81,332 (December 27, 2010). Consequently, service connection for the Veteran's squamous cell carcinoma of the tonsil with metastasis is not warranted on a presumptive basis as related to herbicide exposure in the Republic of Vietnam. Regardless of whether a claimed disability is recognized under 38 C.F.R. § 3.309(e), a claimant is not precluded from presenting evidence that a claimed disability was due to or the result of herbicide exposure. Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). On the issue of direct service connection, the Board notes that STRs are silent regarding any type of cancer, to include squamous cell carcinoma. STRs do reflect treatment for a recurrent ganglion cyst of the left wrist with surgical removal in October 1979. The Veteran was also treated for gonorrhea in June 1968, non-specific urethritis in November 1977, and as a precaution against an ovary infection that his wife had in December 1978. There is no indication of any treatment for human papilloma virus (HPV). STRs also document treatment for such complaints as earaches, upper respiratory infections, back pain, colds, headaches, and sore throats. An entry from August 1983 noted that the Veteran had been a pack-a-day smoker for 25 years. Post-service private medical records dated from 1990 to 1997 do not reflect any diagnosis of cancer of any type. They reflect treatment for complaints such as right shoulder pain, otitis externa, possible bronchitis, eustachian tube dysfunction, early cellulitis of the left ear, neck strain from a motor vehicle accident (MVA), ganglion cyst of the right wrist, and carpal tunnel syndrome (CTS). VA examinations conducted for unrelated problems in 1998 contain no evidence of cancer. The Veteran was diagnosed with left ear hearing loss, myopia, left esotropia, photophobia, combined eye strain/tension-type headaches, ganglion of both wrists with surgery on the left wrist, fracture of the metacarpal necks of the 2nd, 3rd, 4th, and 5th fingers of the right hand, and very slight mild scoliosis, left thoracic and right lumbar spine. Private treatment records dated from July to October 2004 indicate that squamous cell carcinoma was confirmed by way of a biopsy. The appellant's May 2006 NOD consists of a statement and several attachments. In her statement, the appellant noted that the Veteran had served in Vietnam and was presumed to have been exposed to Agent Orange. She stated that the pathology that caused the Veteran's death was known and cited to the cause of death listed on the death certificate. The statement contained a specific discussion of medical record entries covering a period of years. It appears from the content of the statement, and the discussion of medical record entries, that a medical professional prepared both. The information is detailed and specific. However, the appellant has not provided any information as to the preparer being anyone other than herself. Furthermore, as discussed above, the medical record entries cited pertain to records that she has not provided to VA or identified, despite being asked to do so. See June 2011 Letter. The appellant's February 2007 substantive appeal includes a detailed opinion from Dr. Adams, PhD, a clinical psychologist who is board certified in pain management and behavioral medicine. The statement from Dr. Adams is similar to the statement submitted by the appellant with her NOD. There is also an analysis of medical record entries that is similar to those submitted with the NOD. Dr. Adams opined that the Veteran's cancer was the result of a number of factors that were connected to the Veteran's service, to include chronic pain and exposure to Agent Orange. In addition to his February 2007 statement, Dr. Adams referenced a number of medical record entries that he labeled as "Service Medical Record Excerpts." Such a label is incorrect as the references include records dated after the Veteran's retirement in November 1984. He also referenced post-service medical entries to support his theory of causation. His theory of causation is: Conceded exposure on 2 deployments to Vietnam to Agent Orange. AO + HPV + smoking + male gender + sympathetically mediated neuropathic pain + immunosuppresion + overuse syndrome from keyboard work + multiple contraindicated surgery, ice, binding + Time (11 years of inappropriate/delayed care without appropriate specialty consults when repeated treatment failure repeatedly invalidated physicians' diagnostic hypotheses). Paragraph 6.B. of his statement, identified as Exhibit 1. During the May 2007 DRO hearing, Dr. Adams testified that the Veteran suffered from years of unresolved chronic pain during service, and that this "may have contributed to the combination of causes that ultimately resulted then . . . years later, in the squamous cell carcinoma of the tonsil." DRO Hearing Transcript at 5. He noted that the Veteran's complaints of right wrist pain continued after removal of a cyst, and that the Veteran was eventually diagnosed with CTS. He also noted that the Veteran was treated for ear and back pain during service, and opined that the ear pain was the first sign of the Veteran's cancer. He explained that persistent chronic pain "leads to alteration of structured function and DNA at the nervous system level" and that when combined with other factors - in this case, exposure to HPV, cigarette smoke, and sun exposure - could result in squamous cell carcinoma years later. Id. at 6-7. He referenced three epidemiological studies on squamous cell carcinoma of the tonsil. Dr. Adams testified that the Veteran's unresolved chronic pain during service "certainly suggests that something was developing at the tonsil level." Id. at 15. In January 2011, a VA staff physician reviewed the claims folder and offered an opinion with regard to etiology of the Veteran's squamous cell carcinoma. He noted the Veteran's history of tobacco use. He also noted that well-accepted risk factors for oral pharyngeal squamous cell carcinoma include HPV, tobacco use, alcohol consumption, a vegetable and fruit deficient diet, chewing betel quid, and ingestion of mate infusion. He reviewed the claims file and Dr. Adams' statement attached to the February 2007 substantive appeal and concluded that there is no evidence that the Veteran's cancer was related to any incident of service. He indicated that a nexus opinion in this case would require speculation. In October 2011, the Associate Chief of Staff for External Clinical Services for the VA San Diego Healthcare System reviewed the claims folder and offered a detailed opinion with regard to etiology of the Veteran's squamous cell carcinoma. He indicated that he and a VA hematologist-oncologist had reviewed the file - to include STRs, private medical records, Dr. Adams' February 2007 opinion, and Dr. Adams' May 2007 testimony. With respect to the STRs, he noted that the Veteran was treated at least three times for urethritis, but that there were no symptoms that might signify a viral etiology to HPV. He also noted that the Veteran smoked at least one pack of cigarettes per day beginning in approximately 1966 and continuing during his entire time in the military. He noted that the removal of a ganglion cyst from the Veteran's right wrist was successful, with no sequelae noted. Removal of a ganglion cyst from the Veteran's left wrist required wound treatment and he continued to report pain in that area prior to discharge. With respect to post-service treatment records, the reviewer noted that the Veteran was treated for various ear symptoms, all of which were found to have known causes and were minor in nature. He noted that while the Veteran stopped smoking in 1998, an August 2004 treatment note indicated that the Veteran abused alcohol. With respect to Dr. Adams' February 2007 opinion, the VA reviewer observed that the doctor had "selectively excerpted" many parts of the STRs and that his summary of the STRs contained "multiple errors." He stated that because Dr. Adams is not a physician, he "fails to demonstrate an understanding of the clinical expectations, medical course, and outcomes of many of the Veteran's visits to military medical facilities between 1962 and 1984." He noted that the Veteran's complaints of back, shoulder, ear, and neck pain "are among the most common complaints in ambulatory medicine." He also noted that with the exception of wrist pain, the Veteran's symptoms were self-limited. The reviewer also observed that there were no findings in the oral cavity pointing to tonsillar carcinoma until July 2004. The October 2011 reviewer opined that "it is at least as likely as not (>51% certainty)" that the Veteran's tonsillar carcinoma "did not arise in any relation to the Veteran's service." He explained there is no evidence that the cancer was present prior the Veteran's discharge in 1984 or during the 1990's. He stated that there can be a latency period of many years during which a tissue undergoes the changes which we ultimately call a cancer, but that a person does not have cancer until such diagnosis can be made clinically and pathologically. He found no evidence of "spreading as a function of DNA mutations caused by chronic intractable pain" since the Veteran was pain free for most of the time from 1979 to 2004. He noted that the ganglion cysts on both of the Veteran's wrist were benign and did not involve the nerves. He acknowledged that the Veteran had a 20-year history of recurrent painful gangiomata of both wrists, but found no evidence of a neuroma. The reviewer wrote: "PAIN DOES NOT CAUSE CANCER." (Emphasis in original). The October 2011 reviewer further opined that it is at least as likely as not that the Veteran's cancer was caused by smoking and alcohol consumption and "bore no relation to chronic pain of any kind from any source." He noted that alcohol consumption and tobacco use are the two greatest risks for tonsillar carcinoma, and that the Veteran used both substances for many years. The reviewer acknowledged that since the Veteran's tumor was not tested for HPV it could not be excluded as an HPV-associated cancer even in light of the Veteran's other risk factors. However, he concluded that while the Veteran "might have had HPV" given his history of recurrent sexually transmitted disease, such speculation is not supported by the clinical history, physical findings, or tonsillar tissue or serologic proof. He also noted that squamous cell carcinoma of the tonsil has not been shown to be related to herbicide exposure despite extensive study. The reviewer stated that the other risk factors mentioned by Dr. Adams were either speculative or not supported by any "clinician or examination evidence." There are significant factors that cause the Board to favor the October 2011 VA medical opinion over the opinions provided by Dr. Adams. The VA reviewer, a medical doctor, concluded that the Veteran's cancer was caused by his smoking and alcohol use. Notably, he stated that these risk factors are well known causes of squamous cell carcinoma. He could not find any medical evidence to support an association between exposure to herbicides and squamous cell carcinoma. Furthermore, he emphasized that chronic pain does not cause cancer. Dr. Adams is not a medical doctor. His opinion appears speculative in nature. Service connection may not be based on medical opinions which are speculative general, or inconclusive in nature. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical evidence which merely indicates that the alleged disorder "may or may not " exist or "may or may not" be related to service, is too speculative to establish the presence of the claimed disorder or any such relationship). In addition, his theory of causation is a tenuous one that relies on speculation across several links in a chain of causation uncorroborated by competent medical evidence. The Board accepts the October 2011 VA opinion as being the most probative medical evidence on the subject, as it is fully articulated with clear conclusions based on an accurate factual premise and is supported by sound reasoning. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board acknowledges the medical treatise evidence pertaining to the pathogenesis of pain that was submitted at the May 2007 DRO hearing. However, the Board concludes that the document provided is too general in nature to provide the favorable or unfavorable evidence to show that the Veteran's service caused his current disability. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998). Medical treatise evidence can provide important support when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222, 228 (1999). Medical treatise evidence must provide more than speculative or generic statements not relevant to the veteran's claim but must discuss generic relationships with a degree of certainty for the facts of a specific case. Wallin v. West, 11 Vet. App. 509, 514 (1998). In this instance, the medical treatise evidence simply does not provide statements relevant to the facts of this specific case. Although the treatise indicates that chronic pain may lead to neuroplastic changes in the nervous system, it does not endorse any conclusion that chronic pain causes squamous cell carcinoma of any other tissue. Thus, the medical article submitted by the appellant is insufficient to establish the required medical nexus opinion for causation. The weight of the evidence is in favor of a conclusion that the cause of the Veteran's death was squamous cell cancer. At the time of his death, the Veteran was service connected for left ear hearing loss, status post undisplaced fracture of the distal 5th metacarpal of the right hand, and residual scar status post ganglion cyst removal, left wrist. There are no service-connected disabilities listed on the Veteran's death certificate as causing or contributing to his death. In addition, squamous cell cancer was diagnosed in July 2004, many years after service and well outside of the one-year period for presumption of the in-service incurrence of a malignant tumor. See 38 C.F.R. §§ 3.307, 3.309. The Board also points out that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a finding of service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Finally, there is no competent evidence that the Veteran was exposed to mold and/or toxic substances during service. The references to post-service civilian exposure to any toxins is not helpful to the appellant's case because service connection may not be awarded for disability traceable to disease or injury incurred following active military service. The Board recognizes the appellant's sincere belief that the Veteran's death was related in some way to his military service. The appellant claims to have worked in the health care field for many years. See July 2010 Statement. However, as discussed above, she has not been shown to have the professional expertise necessary to provide meaningful evidence regarding a causal relationship between the Veteran's death and his active military service, including any claimed exposure to herbicides. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The preponderance of the evidence is against the claim for service connection for the cause of the Veteran's death. Gilbert v. Derwinski, 1 Vet. App. at 57-58. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for the cause of the Veteran's death is denied. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs