Citation Nr: 1312946 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 09-10 711 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty from June 1955 to July 1976. The Appellant seeks benefits as his surviving spouse. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in September 2007 of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2010, the Board remanded the appeal for further development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directive. Stegall v. West, 11 Vet. App. 268, 271 (1998). Pursuant to 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, in December 2012, the Board obtained an advisory opinion from an independent medical expert outside of VA on the question of service connection for the cause of the Veteran's death. The Board then furnished a copy of the opinion to the Appellant and her representative and afforded them the opportunity to submit additional evidence or argument. In February 2013, the Appellant responded that she had no further argument or evidence to submit. The Appellant's representative did submit additional argument. FINDINGS OF FACT 1. According to the death certificate, the Veteran died in April 2007, and the cause of death was metastatic pancreatic cancer (hereafter referred to as pancreatic cancer) and no other condition was listed as contributing to death. 2. The Veteran's fatal pancreatic cancer did not have onset in service, pancreatic cancer was not manifested to a compensable degree within the one-year period following separation from service, and pancreatic cancer was unrelated to an injury, disease, or event in service, including exposure to Agent Orange. 3. The Veteran's service-connected disabilities were recurrent pancreatitis, myocardial infarction, hiatal hernia, keratitis of the left eye, diabetes mellitus, bilateral hearing loss, and tinnitus with a combined rating of 60 percent. 4. Neither recurrent pancreatitis, myocardial infarction, hiatal hernia, keratitis of the left eye, diabetes mellitus, bilateral hearing loss, nor tinnitus caused or aggravated pancreatic cancer or caused or contribute materially to the cause of the Veteran's death. CONCLUSION OF LAW The fatal pancreatic cancer was not incurred in or aggravated by service, service connection for pancreatic cancer may not be presumed under either the provisions for a chronic disease or for exposure to Agent Orange, pancreatic cancer was not caused by or aggravated by service-connected recurrent pancreatitis or any other service-connected disability, and a service-connected disability did not cause or contribute substantially to the cause of the Veteran's death. 38 U.S.C.A. §§ 1110, 1112, 1116, 1131, 1137, 1310, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.312 (2011). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) , VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for dependency and indemnity compensation, including a claim of service connection for the cause of the Veteran's death, notice under 38 U.S.C.A. § 5103(a) must 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 the claim based on a previously service- connected condition, and (3) an explanation of the evidence and information required to substantiate the claim based on a condition not yet service connected. Hupp v. Nicholson, 21 Vet. App. 342 (2007). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post- adjudication VCAA notice by letters, dated in July 2007 and in December 2010. The Appellant was notified of the type of evidence that was required to substantiate the claim for the cause of death. She was notified that VA would obtain service records, VA records, and records of other Federal agencies, and that she could submit other records not in the custody of a Federal agency, such as private medical records. As for content of the VCAA notice, the documents substantially complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of the claim, except for the effective date of the claim and the degree of disability assignable); and of Hupp v. Nicholson, 21 Vet. App. 342 (2007) (an explanation of the evidence and information required to substantiate the claim based on a previously service-connected condition, and an explanation of the evidence and information required to substantiate the claim based on a condition not yet service connected). To the extent that the VCAA notice came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The timing defect was cured as after the RO provided content-complying VCAA notice the claim was readjudicated as evidenced by the supplemental statement of the case, dated in May 2011. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained the Veteran's service records, VA records, and private medical records. Further, VA has conducted necessary medical inquiry in an effort to substantiate the claim. 38 U.S.C.A. § 5103A(a). The Board has obtained an advisory opinion from an independent medical expert (IME opinion) outside of VA. As the IME opinion is based on a review of the Veteran's history and as medical analysis was applied to the facts of the case to reach the conclusion rendered in the opinion, the IME opinion is adequate to decide the claim. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding a medical opinion is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Appellant in developing the facts pertinent to the claim is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSION Legal Principles for Establishing Service Connection for the Cause of Death When a Veteran dies from a service-connected disability, the Veteran's surviving spouse is entitled to dependency and indemnity compensation. 38 U.S.C.A. § 1310. A death will be considered to result from a service-connected disability when the evidence establishes that such disability, which is causally related to service, was either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a). For a service-connected disability to constitute a principal cause of death, it must be shown to be the primary cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). For a service-connected disability to constitute a contributory cause of death, it must be shown to have contributed substantially and materially to death; combined to cause death; aided or lent assistance to the production of death; or resulted in debilitating effects and general impairment of health to an extent that would render the veteran materially less capable of resisting the effects of other disease or injury causing death, as opposed to merely sharing in the production of death. 38 C.F.R. § 3.312(c). Although there are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, even in such cases, consideration must be given to whether there may be a reasonable basis to hold that a service-connected condition was of such severity as to have a material influence in accelerating death, where the service-connected condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c). Generally, to establish service connection for a disability, the evidence must show: (1) a disability; (2) an in-service incurrence or aggravation of the disability; and (3) a causal relationship between the disability and service, the so-called "nexus" requirement. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). 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." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection may be granted for a disability which is proximately due to or the result of a service-connected disability or for increased in disability caused by a service connected disorder. 38 C.F.R. § 3.310(a). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for specifically listed chronic diseases, including malignant tumors, cancer, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112 and 1137; 38 C.F.R. §§ 3.307, 3.309. A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era (beginning in January 1962 and ending in May 1975) shall be presumed to have been exposed during such service to certain herbicide agents, including an herbicide commonly referred to as Agent Orange. 38 U.S.C.A. § 1116(a)(3); 38 C.F.R. §§ 3.307, 3.309. If a Veteran was exposed to an herbicide agent during active military service, certain listed diseases will be presumed to have been incurred in service if manifest to a compensable degree within specified periods, even if there is no record of such disease during service. 38 U.S.C.A. § 1116(a)(2); 38 C.F.R. §§ 3.307(a)(6), 3.309(e). The Secretary of VA has determined that a presumption of service connection based on exposure to Agent Orange is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. Notice, 59 Fed. Reg. 341 -346 (1994); Notice, 61 Fed. Reg. 41442-41449 and 57586-57589 (1996); Notice, 67 Fed. Reg. 42600-42608 (2002); Notice, 68 Fed. Reg. 27630-27641 (2003); and Notice, 72 Fed. Reg. 32395-32407 (2007); Notice, 75 Fed. Reg. 32540 (2010). Notwithstanding the aforementioned provisions relating to presumptive service connection for a disease associated with exposure to Agent Orange, which arose out of the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2, 725, 2,727-29 (1984), and the Agent Orange Act of 1991, Pub. L. No. 102-4, § 2, 105 Stat. 11 (1991), a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and from the weight of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the weight or probative value of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Facts According to the death certificate, the Veteran was 70 years old when he died in April 2007. The immediate cause of death was metastatic pancreatic cancer. No other condition was listed as contributing to the cause of death. An autopsy was not done. The Veteran served on active duty from June 1955 to July 1976, and he served in Vietnam from January 1968 to September 1968. In July 1976, the Veteran retired after 21 years of military service. The service treatment records document a long history of abdominal pain, which was diagnosed and treated as acute recurrent pancreatitis. There was no finding, history, or treatment of pancreatic cancer. On a retirement examination in May 1976, conducted by a United States Air Force physician, history included acute and recurrent pancreatitis with hospitalizations in April 1970 and May 1971 for acute gastritis and in July 1973 for acute pancreatitis. In June 1976 on a consultation for recurrent pancreatitis with a gastroenterologist, the gastroenterologist stated that the Veteran had no known complications of acute pancreatitis, such as pseudocyst, jaundice, known sepsis, or indigestion and no demonstrable calcifications by X-ray, as well as no weight loss, diarrhea, clinical manifestations of steatorrhea, anemia, or other known nutritional deficiencies. As for the assessment, the gastroenterologist stated that the most probable diagnosis was acute recurrent pancreatitis, which was also encompassed in a diagnosis of chronic pancreatitis, based on the lack of pancreatic calcification, overt diabetes mellitus, or pancreatic insufficiency. The gastroenterologist also stated that the finding of chemical diabetes did not constitute proof of a pancreatic endocrine insufficiency on the basis of chronic destructive pancreatitis. In an addendum to the retirement examination, dated in July 1976, after a review of the consultation by the gastroenterologist, the Air Force physician stated that after diagnostic testing suggested by the gastroenterologist the final of summary of defects included acute recurrent pancreatitis with no evidence of active disease. After service, in a rating decision in February 1977 the RO granted service connection for recurrent pancreatitis, hiatal hernia, and left eye keratitis. Records from Kaiser Permanente show that on hospitalizations in January 1981 the diagnoses were pancreatitis and a history of an anterior myocardial infarction and chronic recurrent pancreatitis, in May 1981, the diagnosis was acute relapsing pancreatitis, in August 1981, the diagnosis was chronic relapsing pancreatitis, and in January 1988, the diagnosis was pancreatitis. Records from Kaiser Permanente in March 1988 show that a computerized tomography scan suggested chronic pancreatitis and a differential diagnosis of cancer of the pancreas. The postoperative diagnosis was that the findings were more consistent with chronic pancreatitis and less suggestive of a tumor. In September 1994, the Veteran's then current health problems included pancreatitis, a hiatal hernia, and a possible ulcer. In August 1999, history included pancreatitis. On VA examination in May 2006, the Veteran appeared fit. There were no signs of anemia or acute pancreatitis. The diagnoses were hiatal hernia and recurrent pancreatitis. In February 2007, VA records show that the Veteran presented with a complaint of losing twenty pounds in three months. X-rays had shown solid liver lesions suggesting metastases. The assessment was unexplained weight loss (suspect liver metastases), gastroesophageal reflux disease, and pancreatitis. A computerized tomography scan showed multiple lesions in the liver and a mass in the pancreatic head, suspicious of pancreatic adenocarcinoma. In March 2007, after a liver biopsy, the results were positive for malignancy and for metastatic adenocarcinoma. And the biopsy supported a primary diagnosis of metastatic pancreatic adenocarcinoma. The Veteran died in April 2007. The death certificate lists the cause of death as metastatic pancreatic cancer. The interval between the onset of the cancer and death was months. At the time of his death, the Veteran was service-connected for recurrent pancreatitis and hiatal hernia (rated 30 percent), myocardial infarction (rated 30 percent), keratitis of the left eye (rated zero percent), diabetes mellitus (rated 10 percent), for bilateral hearing loss (rated zero percent), and tinnitus (rated 10 percent). The combined disability rating was 60 percent. In July 2007, a VA physician reviewed the Veteran's file and indicated that the central question was whether or not the chronic recurrent pancreatitis materially increased the risk for pancreatic cancer. The VA physician stated that such a question had not yet been decided in the medical literature. The VA physician stated that the available medical literature did not indicate any possible association of pancreatic cancer and pancreatitis on an as likely as or more likely than not basis. In March 2009, the Appellant submitted several articles on the subject of a relationship between chronic pancreatitis and pancreatic cancer, including a study in May 1993, published by the New England Journal of Medicine, which concluded that the risk of pancreatic cancer was significantly elevated in subjects with chronic pancreatitis. In light of the conflicting medical evidence, in December 2010, the Board obtained an IME opinion from a gastroenterologist. The opinion is addressed in the Analysis under the heading "Medical Evidence." Analysis In the Analysis, the term recurrent pancreatitis is encompassed in the term chronic pancreatitis and the terms are used interchangeably. The Board must consider all pertinent lay and medical evidence. 38 U.S.C.A. § 1154(a). In determining whether lay or medical evidence may be considered, that is, meets the threshold of admissibility, the lay and medical evidence must be competent evidence. Rucker, 10 Vet. App. at 74. Competency is a question of fact, which is to be addressed by the Board. Jandreau, 492 F.3d at 1377. The Appellant as a lay person is competent to describe her personal observations, such as symptoms of an illness, which are within the realm of her personal knowledge and does not require that she have specialized education, training, or experience. See 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person); see Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (Lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. Cause of Death There is no argument by the Appellant or competent lay or medical evidence that raises a reasonable possibility that pancreatic cancer, as shown on the Veteran's death certificate in April 2007, had onset during the Veteran's period of service from June 1955 to July 1976 or that pancreatic cancer as a chronic disease was manifest to a compensable degree within the one year presumptive period, following the Veteran's service in July 1976, or that pancreatic cancer, excluding the service-connected disabilities and exposure to Agent Orange, was due to an injury, disease, or event in service. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Excluding recurrent pancreatitis, there is no argument by the Appellant or competent lay or medical evidence that raises a reasonable possibility that pancreatic cancer was caused by or aggravated, that is, permanently made worse by any service-connected disability, namely, myocardial infarction, hiatal hernia, keratitis of the left eye, diabetes mellitus, bilateral hearing loss, or tinnitus. 38 C.F.R. § 3.310. Excluding recurrent pancreatitis, there is no argument by the Appellant or competent lay or medical evidence that raises a reasonable possibility that any service-connected disability, namely, myocardial infarction, hiatal hernia, keratitis of the left eye, diabetes mellitus, bilateral hearing loss, or tinnitus caused or contributed materially to the cause of the Veteran's death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. Pancreatic cancer is not a disease that is presumed to be service-connected for the Veteran who served in Vietnam and was exposed to Agent Orange under 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307 and 3.309, and there is no argument by the Appellant or competent medical evidence that raises a reasonable possibility that pancreatic cancer is actually caused by exposure to Agent Orange. Combee, 34 F.3d at 1042. Excluding consideration of recurrent pancreatitis, which is discussed separately, for the above reasons, pancreatic cancer is not a service-connected disability and a service-connected disability did not cause or contribute materially to cause the Veteran's death. Lay Evidence The Appellant does assert that the Veteran's service-connected recurrent pancreatitis contributed to his death. The Appellant maintains that the Veteran was hospitalized on numerous occasions for pancreatitis and that pancreatitis is a risk factor for developing pancreatic cancer, citing medical studies she submitted. The Appellant as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). To the extent the Appellant has expressed the opinion that recurrent pancreatitis contributed to the Veteran's death, because pancreatitis is a risk factor for developing pancreatic cancer, the Appellant's opinion as a lay person is limited to inferences that are based on personal observation and does not require specialized knowledge, education, or training. Whether recurrent pancreatitis contributed to the Veteran's death is not a question that can be competently answered by the Appellant as a lay person based on mere personal observation as the effects of recurrent pancreatitis fall outside the realm of common knowledge of a lay person, that is, not capable of lay observation, without specialized education, training, or experience. And no factual foundation has been established to show that the Appellant is otherwise qualified through specialized education, training, or experience to render an opinion on a question of medical causation. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (the Board may find that lay evidence to diagnose or to establish medical causation is not competent evidence). Therefore, the Appellant's lay opinion is not competent evidence and the opinion is not to be considered as favorable evidence. As the Appellant's lay evidence is not competent evidence, the Board need not reach the question of credibility. As the Appellant's s lay evidence is not competent evidence on the question of whether recurrent pancreatitis caused or contributed to the cause of the Veteran's death, the Board looks to the medical evidence. The Appellant has submitted evidence, consisting of medical studies to support her claim. Medical Evidence The Appellant has submitted medical studies from the Digestive Diseases and Sciences Journal (2002), American Journal of Physiology-Gastrointestinal and Liver Physiology (2004), and the New England Journal of Medicine (1993) that concluded that pancreatitis increases the risk for developing pancreatic cancer, which goes to the question of whether the service-connected recurrent pancreatitis caused or contributed to the cause of the Veteran's death. Medical studies may be sufficient to establish a causal relationship, but as here the medical studies, alone, are insufficient to determine whether recurrent pancreatitis caused or contributed to the cause of the Veteran's death, the studies can still provide important support of the claim when combined with the opinion of a medical professional. Sacks v. West, 11 Vet. App. 314, 317 (1998). As there was a reasonable possibility that additional evidence necessary to substantiate the claim could be obtained under the duty to assist, the Board requested an advisory opinion from an independent medical expert (IME), a gastroenterologist, outside of VA on the question of service connection for the cause of the Veteran's death. 38 U.S.C.A. § 5103(A)(a). The Board asked the IME, who is qualified through education, training, or experience to render an opinion on the following questions: Did chronic pancreatitis (recurrent pancreatitis) cause pancreatic cancer? And if chronic pancreatitis (recurrent pancreatitis) did not cause pancreatic cancer, then did chronic pancreatitis contributed to the cause of the Veteran's death? The IME expressed the opinion that it was less likely than not (probability of less than 50 percent) that chronic pancreatitis caused pancreatic cancer. The IME explained that although a relationship does exist between chronic pancreatitis and pancreatic cancer, the association is a risk factor and does not represent a causal relationship. The IME stated that most patients with chronic pancreatitis did not develop pancreatic cancer. The IME also expressed the opinion that it was less likely than not (probability of less than 50 percent) that chronic pancreatitis contributed to the cause of the Veteran's death. The IME explained that although the Veteran had been diagnosed with chronic pancreatitis, chronic pancreatitis was not likely a major contributor, especially because a subsequent diagnosis of pancreatic cancer was made. The IME stated that chronic pancreatitis was not an inherent cause of death and chronic pancreatitis did not contribute substantially or materially to the production of death. The IME stated that there was no evidence that the Veteran's chronic pancreatitis had a causal relationship to the subsequent cause of death (metastatic pancreatic adenocarcinoma). The IME stated that although the service-connected chronic pancreatitis affected a vital organ, chronic pancreatitis did not result in debilitating effects and a general impairment of health to the extent that the Veteran was materially less capable of resisting the effects of the primary cause of death. The IME explained that once the diagnosis of metastatic pancreatic adenocarcinoma was made, the prognosis was extremely poor regardless of the presence of chronic pancreatitis. The IME stated that in a majority of patients diagnosed with pancreatic adenocarcinoma, there was no curative surgical or chemotherapy options, and treatment was often limited to palliative care. The probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, whether the opinion is the product of reliable medical principles, and whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion. And a review of pertinent medical literature may also furnish information relevant to the question of causation. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). While the medical studies have some probative value, the medical studies are not persuasive evidence on a material issue of fact, namely, that the service-connected recurrent pancreatitis caused or contributed to the cause of the Veteran's death by pancreatic cancer. As for the IME opinion, the opinion was based on the Veteran's history as was summarized in the Board's request for the opinion and the Veteran's file was sent to the IME. And the IME, who is a gastroenterologist, applied medical analysis to the facts of the case in order to reach the conclusions submitted in the opinion. And the IME reviewed the pertinent medical literature and acknowledged that the literature identified pancreatitis as a risk factor for developing pancreatic cancer, but the IME stated that a risk factor did not represent a causal relationship as most patients with chronic pancreatitis do not develop pancreatic cancer. The IME concluded that it was less likely than not that chronic pancreatitis caused the fatal pancreatic cancer and that it was less likely than not that chronic pancreatitis contributed substantially or materially to the Veteran's death. The IME VA explained that chronic pancreatitis did not result in debilitating effects and a general impairment of health to the extent that the Veteran was materially less capable of resisting the effects of the primary cause of death substantially or materially to the Veteran's death. While the opinion of the VA physician in July 2007 is consistent with the IME's opinion, considering the merits of the analysis and the details of the opinions, the Board places greater weight on the IME opinion, which was based on medical analysis applied to the facts of case, including a review of the medical literature, is persuasive medical evidence against the claim and the IME opinion outweighs the evidence of a pancreatitis as a risk factor for pancreatic cancer as identified in the medical studies. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs