Citation Nr: 1313499 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 12-03 276 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada 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 WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active military service from November 1958 to May 1978. The Veteran died on July [redacted], 2009. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. The appellant appeared and testified at a hearing held before a Decision Review Officer at the RO in January 2012. A copy of the transcript of this hearing has been associated with the claims file. The Board notes that the appellant initially also sought accrued benefits and death pension benefits. By statement received in April 2010, however, the appellant withdrew her claim for death pension. Furthermore, although she stated her belief at the RO hearing held in January 2012 that the claim for accrued benefits was still on appeal, the Board notes that she only disagreed with the denial of DIC benefits in her Notice of Disagreement submitted on January 3, 2010. In the Notice of Disagreement, the first paragraph states: "This letter is to appeal on your decision made for my claim of DIC ...." She makes no mention of the accrued benefits claim denied in the rating decision. Furthermore, there are no statements submitted within one year of the December 2010 rating decision that could be construed as a Notice of Disagreement with the denial of accrued benefits. In addition, her statement made at the January 2012 RO hearing is not timely to constitute a Notice of Disagreement as it was provided over a year after the issuance of the December 2010 rating decision. Consequently, the appellant did not initiate an appeal of the denial of her claim for accrued benefits, and the Board, therefore, has no jurisdiction over such claim. See 38 U.S.C.A. § 7005 (West 2002); 38 C.F.R. § 20.201, 20.302 (2012). This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. The Veteran died on July [redacted], 2009, as a result of acute myeloid leukemia (AML). 2. Although the Veteran served in the Republic of Vietnam from December 1968 to January 1970 and is, therefore, presumed to have been exposed to herbicides during such service, AML is not a disease recognized by VA as being associated with exposure to herbicides in the Republic of Vietnam; nor does the evidence establish an actual causal link between the Veteran's military service and his AML. 3. The evidence fails to establish that the Veteran's AML was proximately due to, the result of or aggravated by his service-connected prostate cancer or treatment therefor in 2004, nor did it cause the Veteran to be so debilitated as to result in a general medical condition rendering him materially less capable of resisting the effects of his AML. 4. The evidence fails to demonstrate that any of the Veteran's other service-connected disabilities of degenerative joint disease/degenerative disc disease of the cervical spine with bilateral upper extremities radiculopathy, degenerative joint disease of the lumbar spine, hemorrhoids, and residuals of fracture to left distal radius significantly and materially contributed to his death. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1310, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance Requirements VA's duties to notify and assist claimants in substantiating a claim for VA benefits are described in 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 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 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 notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, which includes a claim of service connection for the cause of the veteran's death, the United States Court of Appeals for Veterans Claims (Court) has held section 5103(a) notice must be tailored to the claim. Hupp v. Nicholson, 21 Vet. App. 342 (2007). The notice should include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Id. In the present case, notice was provided to the appellant in February 2010, prior to the initial AOJ decision on her claim. The Board finds that the notice provided fully complied with VA's duty to notify. Likewise, the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her claim. She was told it was her responsibility to support the claim with appropriate evidence and has been given the regulations applicable to VA's duty to notify and assist. Indeed, the appellant submitted evidence in connection with her claim demonstrating her actual knowledge of needing to support her claim by providing such evidence. Thus the Board finds that the purposes behind VA's notice requirement have been satisfied, and VA has satisfied its "duty to notify" the appellant, and any error in this regard is harmless. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the veteran has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and available evidence, and VA has notified the appellant of any evidence that could not be obtained. The Board notes that the appellant's representative in its Informal Hearing Presentation submitted in March 2013 argued that additional development should be accomplished to obtain treatment records from the Nellis Air Force Base's Michael O'Callaghan Hospital. The Board notes that, in July 2009 before the Veteran's death, the RO in conjunction with the Veteran's claim for service connection for his AML issued a Formal Finding of Unavailability of these records on the basis that it sent a batch email to this federal hospital and received a batch email in return in which the federal hospital provided a negative response for having any treatment records for the Veteran. Moreover, even if there were treatment records that have not been obtained from this federal hospital, these records would not provide any additional relevant information as claimed by the appellant's representative. The appellant's representative claims that these records are needed because the private hospital that treated the Veteran for his AML, to which the Veteran was transferred from the federal hospital, did not properly obtain their own labs during reevaluation of the Veteran for absolute confirmation of the transferred diagnosis. It additionally argues that the diagnosis never changed or appeared to be questioned from subsequent doctors. The representative appears to be arguing that the reason for the need for these records is to answer the question of whether the Veteran's myeloid leukemia was either acute or chronic. After considering the representative's arguments, the Board finds that the records from the Michael O'Callaghan Hospital would not provide any additional relevant information that would establish the appellant's claim. First, the Board notes that the records of the subsequent private hospitalization are of record and demonstrate that the Veteran underwent extensive testing, to include two bone marrow biopsies, which confirmed the diagnosis of AML. Furthermore, the admission note in these private treatment records indicates that, at the Michael O'Callaghan Hospital, the Veteran was found to have a white cell count of over 700,000 and a high potassium level and, thus, was transferred to the private hospital for emergent oncologic evaluation and possible need for plasmapheresis. This note further indicates the results of a basic metabolic panel conducted at this private hospital. The Oncology consultation report indicates the assessment was acute leukemia with the subtype to be determined. The plan was to obtain peripheral blood flow cytometry and cytogenetics, a bone marrow aspirate and biopsy, and start leukapheresis and high-dose hydroxyurea until the subtype of leukemia is identified. The remaining records show that cytometry and bone marrow biopsy were obtained twice during the Veteran's hospitalization, all of which demonstrated the Veteran had AML. Given this subsequent diagnostic testing confirming the type of leukemia the Veteran had by the private hospital, the Board finds that any diagnosis rendered or testing initially conducted at the time the Veteran was seen in the emergency room at the Michael O'Callaghan Hospital would no longer be relevant in determining the type and nature of the Veteran's leukemia. Consequently, remand for further efforts to obtain these treatment records is not necessary and would unduly delay the adjudication of the appellant's claim. The Board finds that VA, therefore, has made every reasonable effort to obtain all records relevant to the appellant's claim and any records not obtained would not provide any additional relevant information regarding the Veteran's diagnosis of leukemia and its type. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. A medical opinion was obtained in December 2010. The report of the opinion obtained reflects that the examiner reviewed the Veteran's past medical history and rendered an appropriate opinion consistent with the remainder of the evidence of record. The Board, therefore, concludes that the opinion report is adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The appellant and her representative have not contended otherwise. Thus, the Board finds that VA has satisfied its duties to inform and assist the appellant at every stage of this case. Additional efforts to assist or notify her would serve no useful purpose. Therefore, she will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis Dependency and indemnity compensation is payable to a surviving spouse, child, or parent either because of a service-connected death occurring after December 31, 1956, or pursuant to the election of a surviving spouse, child, or parent, in the case of such a death occurring before January 1, 1957. 38 C.F.R. § 3.5. Service connection may be established for the cause of a Veteran's death when a service-connected disability "was either the principal or a contributory cause of death." 38 C.F.R. § 3.312(a); see 38 U.S.C.A. § 1310; see also 38 U.S.C.A. §§ 1110 and 1112 (setting forth criteria for establishing service connection). A service-connected disability is the principal cause of death when that 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). A contributory cause of death must be causally connected to the death and must have "contributed substantially or materially" to death, "combined to cause death," or "aided or lent assistance to the production of death." 38 C.F.R. § 3.312(c)(1). See generally Harvey v. Brown, 6 Vet. App. 390, 393 (1994). Therefore, service connection for the cause of a Veteran's death may be demonstrated by showing that the Veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence or, in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. 38 C.F.R. § 3.303(a); See Walker v. Shinseki, 708 F.3d 1331, 1334 (Fed. Cir. 2013). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). A second way to establish direct service connection is set forth in § 3.303(b). In Walker, the Court of Appeals for the Federal Circuit (Federal Circuit) found that, unlike subsection (a), which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. at 1335-36. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. at 1336. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. at 1336-39. Service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1112, 1133 and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). 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. 38 C.F.R. § 3.159(a)(2). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). The record shows the Veteran died on July [redacted], 2009, due to AML. See death certificate. The appellant filed her claim for DIC seeking service connection for the cause of the Veteran's death shortly thereafter. The appellant has set forth multiple theories of entitlement. The Board will address each one separately. The appellant's main contention is that the Veteran's AML is related to his exposure to Agent Orange when he served in Vietnam. In some circumstances, a disease associated with exposure to certain herbicide agents will be presumed to have been incurred in service even though there is no evidence of that disease during the period of service at issue, unless there is affirmative evidence to establish that the disease is due to an intercurrent injury or disease. 38 U.S.C. § 1116(a); 38 C.F.R. §§ 3.307(a)(6), 3.307(d)(1), 3.309(e). A veteran who served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116(f). The Board notes that the record confirms that the Veteran served in the Republic of Vietnam from December 1968 to January 1970. Thus, he is presumed to have been exposed to herbicides during such service. To be entitled to presumptive service connection, however, the disease for which service connection is sought must be one that VA has recognized as being associated with exposure to herbicides. Diseases that VA has recognized as associated with exposure to herbicides include: AL amyloidosis; chloracne or other acneform diseases consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; ischemic heart disease (including, but 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); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) Note 1; 75 Fed. Reg. 53,202 (August 31, 2010). For purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 75 Fed. Reg. 53,202 (August 31, 2010) (to be codified as Note 3 in 38 C.F.R. § 3.309(e)). The Secretary of VA 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 61 Fed. Reg. 41,442, 41,449 and 57,586, 57,589 (1996). A list of specific conditions not having a positive association was recently published by the Secretary. See Notice, 75 Fed. Reg. 81,332 (December 27, 2010). For presumptive service connection to be warranted, the herbicide-related disease 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, and respiratory cancers within 30 years, 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 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 Vietnam era. The Veteran died of AML. This is confirmed by the final private treatment records that demonstrate the Veteran underwent bone marrow biopsy twice during his hospitalization, both of which showed he had persistent AML. VA has recognized that all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia) are diseases associated with herbicide exposure. In contrast, VA has specifically found that the scientific evidence does not warrant a presumption of service connection for any other leukemias. See 77 Fed. Reg. 155, Determinations Concerning Illnesses Discussed in the National Academy of Sciences Report: Veterans and Agent Orange: Update 2010; p. 47,924 (Aug. 10, 2012). The appellant and her representative have made arguments to the effect that the Veteran's leukemia was chronic and not acute in an attempt to bring it under the umbrella of leukemias for which presumptive service connection has been found to be warranted as due to exposure to herbicides. The Board finds, however, that the arguments of the appellant and her representative miss the point. The real problem in this case with establishing entitlement to presumptive service connection based upon exposure to herbicides in Vietnam is that the Veteran's leukemia was myelogenous (a.k.a. myeloid) rather than lymphocytic. VA has recognized lymphocytic (or lymphoid) leukemia as having a relationship with exposure to herbicides. It has not, however, recognized myelogenous (a.k.a. myeloid) leukemia. The appellant has submitted articles about leukemia to support her claim. Unfortunately, the Board finds that they do just the opposite and support that the Veteran's AML is not a presumptive disability for presumptive service connection purposes based upon exposure to herbicides. The article from Stanford University about leukemia makes it clear that there are essentially two types of leukemia, lymphocytic leukemia that develops in the lymphocytes and myelogenous leukemia that develops in the granulocytes or monocytes (myeloid cells). Hence the difference between the two types is what type of cells the leukemia develops in. Once the type has been determined, then the leukemia is characterized as either acute of chronic. Acute leukemia is where new, immature cells called "blasts" remain immature and cannot perform their tasks. With chronic leukemia, some blast cells are present but they are more mature and are able to perform some of their functions. The medical evidence is clear based upon bone marrow biopsy in May 2009, which was confirmed by another bone marrow biopsy in June 2009, that the Veteran had persistent AML. It is also clear from the evidence that the Veteran's leukemia was acute, not chronic. Since the clear and unmistakable evidence demonstrates that the Veteran's leukemia was myeloid (also called myelogenous) and was acute, it is not the type of leukemia that VA has recognized as having an association to exposure to herbicides, which is chronic lymphocytic leukemias. Since VA as not recognized AML as an enumerated disease for which presumptive service connection has been found to be warranted based upon exposure to herbicides in Vietnam, the Board finds that the preponderance of the evidence is against the appellant's claim that service connection for the cause of the Veteran's death, AML, is warranted on a presumptive basis as due to exposure to herbicides based upon his service in the Republic of Vietnam. The Board has also considered whether there is direct evidence of a link between the Veteran's AML and his military service. The Board notes that the Veteran's service treatment records are silent for any findings consistent with AML. In fact, the post-service medical evidence is clear that the Veteran was not diagnosed to have AML until May 2009, more than 30 years after his separation from active duty. Thus, although leukemia is an enumerated disease in 38 C.F.R. § 3.309(a), the Board finds that there is no evidence of a chronicity in service or a continuity of symptomatology since service, such that service connection could be granted under 38 C.F.R. § 3.303(b) without further nexus evidence. Consequently, in order for direct service connection to be granted, there must be competent, credible and probative nexus evidence that the Veteran's AML was related to his military service, including his presumed exposure to herbicides while serving in the Republic of Vietnam. In that regard, the Board notes that the appellant has submitted multiple statements from the Veteran's oncologist who treated him for his AML. The first letter is dated in July 2009 and was submitted by the appellant in October 2009. In this letter, the oncologist states the Veteran died as a result of AML and that he had been exposed to Agent Orange in the past which has been linked to the development of acute leukemia. The second letter is dated in April 2010. In it, the oncologist states that the Veteran died of acute myelogenous leukemia. He noted that the Veteran had been exposed to Agent Orange and also had prostate cancer. He then stated that Agent Orange exposure has been linked to the development of prostate cancer and leukemia and that some studies have shown a higher risk of leukemia in patients with prostate cancer. As to direct service connection, the Board finds that these private medical opinions lack probative value because the examiner fails to provide a reasonable rationale for his opinion or cite to any studies or other authority for the proposition that acute leukemia has been linked to exposure to Agent Orange, when in fact, based upon scientific study by the National Academy of Science, VA has determined otherwise. Furthermore, especially in his second opinion, he fails to make a distinction between acute and chronic, as well as myelogenous and lymphocytic, leukemias in rendering his opinion. It is correct that medical evidence has linked exposure to Agent Orange with the development of leukemia, but not all leukemias, only B-cell (i.e., lymphocytic) leukemias. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.). Consequently, as the private oncologist provides no fully articulated, sound reasoning for the opinions he provides, the Board finds they have no probative value and, therefore, are not sufficient evidence to establish the necessary nexus requirement for service connection. Finally, the Board notes that the appellant's testimony and statements lack value to establish a link between the Veteran's military service and his AML. It is clear from reading her statements that she is not competent to provide a link between the Veteran's herbicide exposure and his AML. The Board notes that the appellant is competent to provide testimony concerning factual matters of which she has firsthand knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The presence and the cause of AML, however, is a determination "medical in nature" and not capable of lay observation. A layperson is generally not deemed competent to opine on a matter that requires medical knowledge, such as the question of whether a chronic disability is currently present or a determination of etiology. See 38 C.F.R. § 3.159(a)(1) (Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions). Therefore, the Board finds that the appellant's lay opinion relating the Veteran's AML to his military service, especially to exposure to herbicides in Vietnam, is not probative nexus evidence. For the foregoing reasons, the Board finds that the preponderance of the evidence is against finding that there is a direct relationship between the Veteran's AML and his military service, to include his presumed exposure to herbicides while serving in Vietnam. Finally, the Board notes that, although leukemia is an enumerated chronic disease for presumptive service connection under 38 C.F.R. § 3.307(a), the Board finds that the evidence fails to demonstrate that the Veteran's AML manifested to a compensable degree within one year after service. In fact, the evidence clearly demonstrates he was not diagnosed to have AML until May 2009, more than 30 years after his discharge from active military service. Consequently, the preponderance of the evidence is also against finding that presumptive service connection on this basis is warranted. The appellant raises a second theory of entitlement, however, which is that the Veteran's AML was secondary to his service-connected prostate cancer or treatment therefor that he received in 2004. She has also alleged that the Veteran's prostate cancer weakened him so that he was unable to fight off the AML thereby essentially claiming that his service-connected prostate cancer substantially and materially contributed to his death. 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). Generally, minor service-connected disabilities, particularly those of a static nature or not affecting a major organ, would not be held to have contributed to death primarily due to an unrelated disability. 38 C.F.R. § 3.312 (c)(2). 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, rendering the veteran materially less capable of resisting the effects of the other diseases primarily causing death. Where the service-connected condition affects the vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. 38 C.F.R. § 3.312(c)(3). In support of her claim, she submitted articles that risk factors for AML include prior history of prostate cancer and radiation exposure. These articles, however, indicate that it is exposure to either chemotherapy or external beam radiation therapy for prostate cancer that are shown to potentially increase the risk of developing AML. In the present case, the Veteran's prostate cancer in 2004 was treated with brachytherapy, which is the implantation of radiation seeds directly into the prostate. Although clearly involving radiation, none of these articles relate treatment of prostate cancer with brachytherapy to be a risk factor for developing AML later. Furthermore, the Board notes that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999).; see also Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). The articles submitted by the appellant were not accompanied by the opinion of any medical expert linking the Veteran's AML to his service-connected prostate cancer or treatment therefor in 2004. Thus, the medical articles submitted are, in and of themselves, insufficient evidence to establish the required medical nexus. In addition, the April 2010 letter from the Veteran's oncologist states that "some studies have shown a higher risk of leukemia in patients with prostate cancer." The oncologist, however, failed to identify any of those studies. Furthermore, as previously indicated, the articles submitted by the appellant do demonstrate a higher rate of AML in prostate cancer patients who were treated with chemotherapy or external beam radiation therapy but not brachytherapy like the Veteran was. Thus, the oncologist's failure to address the Veteran's specific treatment for his prostate cancer is problematic. Finally, his statement is very general and fails to specify that Veteran's particular type of leukemia was shown to have a higher rise in patients with prostate cancer. The oncologist further failed to explain his statement of why there is a higher rise of leukemia in patients with prostate cancer. Thus, the Board finds that the oncologist's statement is not probative as he fails to provide a sufficient rationale for his statement. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.). Therefore, the oncologist's April 2010 statement is not sufficient to establish a nexus relationship between the Veteran's prostate cancer and his later developing AML. Furthermore, the appellant has made arguments to the effect that it was never confirmed that the Veteran's prostate cancer had resolved. This argument echoes the argument made by the Veteran during his lifetime when the disability rating for his service-connected prostate cancer was reduced from 100 percent to 20 percent effective April 1, 2007. The Board notes, however, that a VA examination conducted in July 2007 demonstrates that the Veteran's last PSA taken in April 2007 was 0.4 and that the examiner stated there was no evidence of active prostate cancer. There is no medical evidence thereafter to demonstrate that the Veteran had a recurrence of his prostate cancer such that a 100 percent disability rating would have been warranted. Consequently, debilitation cannot be presumed. 38 C.F.R. § 3.312(c)(3). Finally, the Board notes that, in December 2010, the RO obtained a VA medical opinion to address the appellant's contentions. After reviewing the claims file, the VA physician noted the pertinent facts, including the Veteran's service-connected disabilities, that he had prostate cancer in 2004 treated with brachytherapy, and that he presented in "blast crisis" on May 10, 2009 and died shortly after of AML. He also indicated that literature was reviewed and noted that there is no reported association between brachytherapy and the future onset of AML. Thus, the VA physician opined that the Veteran's service-connected prostate cancer and it's treatment did not substantially contribute or hasten his death due to AML due to lack of medical plausibility. The Board finds the VA physician's medical opinion to be highly probative and persuasive. It is clear he reviewed the claims file as well as relevant literature and found there was no relationship between the Veteran's treatment with brachytherapy for his prostate cancer and his later development of AML. Furthermore, based upon his review of the record, the VA physician found that there was a lack of medical plausibility based upon the evidence that the Veteran's prostate cancer contributed to or hastened the Veteran's death due to AML. The Board also finds that the medical evidence prior to the Veteran's death relating to his prostate cancer demonstrates it was in remission and, although it caused some residual difficulties with urinary incontinence and erectile dysfunction, it did not cause the Veteran to have general malaise or fatigue such that a finding can be made that his prostate cancer resulted in him being so debilitated as to cause general impairment of health, rendering him materially less capable of resisting the effects of his AML. Therefore, the Board finds that the preponderance of the evidence is against finding that the Veteran's AML was proximately due to, the result of or aggravated by his service-connected prostate cancer or treatment therefor or that his service-connected prostate cancer contributed to the Veteran's death. The Board has also considered whether the Veteran's service-connected disabilities other than his prostate cancer may have contributed to his cause of death given the appellant's multiple statements that the Veteran had fatigue, shortness of breath, and body aches throughout his lifetime after service. She has stated that his fatigue, shortness of breath and body aches were are symptoms of leukemia and thus indicate his leukemia was dormant for many years. There is no evidence to support such an assertion. The Board notes, however, that the Veteran was service-connected for multiple musculoskeletal disorders to include degenerative joint disease/degenerative disc disease of the cervical spine with bilateral upper extremities radiculopathy and degenerative joint disease of the lumbar spine for which service connection had been initially established in 1978 for degenerative joint disease of the cervical and lumbar spines, then degenerative disc disease of the cervical spine was added in 1991 and bilateral upper extremities radiculopathy was added in 2008. These disabilities could likely account for the Veteran's fatigue and body aches, and possibly also his shortness of breath, as the VA examination conducted in July 2007 demonstrated he had significant physical limitations as a result of these musculoskeletal disabilities. VA treatment records from 2008 show that, although he complained of neck and back pain, his disabilities were essentially static, meaning there is no evidence that they were worsening. Nor is there evidence that they were affecting any major organ. Furthermore, there is no record of treatment for hemorrhoids or the residuals of the fracture to the left distal radius. The July 2007 VA examination showed there were no present complications resulting from those service-connected disabilities. Consequently, under 38 C.F.R. § 3.312(c), the Board finds that there is no basis for finding that these service-connected disabilities were a contributory cause of his death as these disabilities were static and did not affect any major organ. The appellant also made statements to the effect that the Veteran had problems with sinus infections that she relates to his exposure to Agent Orange in Vietnam. However, the Veteran was not service-connected during his lifetime for sinus infections or any chronic upper respiratory disorder. Nor did he ever file a claim for service connection for such a disability. Furthermore, despite her statements, the appellant has submitted no evidence to support that there was any link between the Veteran's alleged chronic sinus infections and his military service. The Board notes that such condition is not a disease that has been recognized by VA as being associated with exposure to herbicides in the Republic of Vietnam. See 38 C.F.R. § 3.309(e). Finally, the Board notes that the appellant has not provided any evidence other than her own statements that any chronic sinus condition the Veteran may have had contributed to his death. For the foregoing reasons, the Board finds that the preponderance of the evidence is against finding that the Veteran's AML, which caused his death in July 2009, is either related to his military service (either on a direct or presumptive basis) or that a service-connected disability, especially the Veteran's prostate cancer or treatment therefor, contributed to the Veteran's death either by causing or aggravating his AML or by resulting in such debilitation that they caused general impairment of health rendering the Veteran materially less capable of resisting the effects of his AML. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection for the cause of the Veteran's death must, therefore, be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs