Citation Nr: 1316301 Decision Date: 05/17/13 Archive Date: 05/29/13 DOCKET NO. 09-35 289 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for the cause of the Veteran's death. WITNESS AT HEARINGS ON APPEAL Appellant REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. D. Simpson INTRODUCTION The Veteran served on active duty from March 1969 to July 1971. He had an additional unverified period of service. He died in January 2009. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In October 2010 and March 2012, the appellant was afforded hearings before the undersigned on her claim. Hearing transcripts are of record. In May 2011, the Board remanded the claim for additional development. In May 2012, the Board awarded service connection for schizophrenia for accrued benefit purposes. The claim for service connection for the cause of the Veteran's death was remanded for additional development and readjudication in light of the newly recognized service-connected disability. The agency of original jurisdiction (AOJ) issued its most recent supplemental statement of the case (SSOC) in October 2012. Since then, the appellant has submitted additional pertinent evidence that has not been considered by the AOJ. In October 2012, she submitted a waiver of review by the AOJ. The Board may consider the newly submitted evidence in the first instance. 38 C.F.R. § 20.1304(c). A review of the Virtual VA paperless claims processing system does not show any pertinent evidence that has not already been associated with the claims folder. FINDINGS OF FACT 1. The Veteran died in January 2009 due to metastatic pancreatic cancer. 2. The Veteran's development of pancreatic cancer was not attributable to any service-connected disability or in-service event. CONCLUSION OF LAW The criteria for the award of service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1310, 5107(b) (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 Duty to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In the context of a claim for DIC benefits, § 5103(a) notice must include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or 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. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). The Board finds that all notification action needed to make a decision has been accomplished. Through a February 2009 notice letter, the RO notified the appellant of the information and evidence needed to substantiate a claim of service connection for the cause of the Veteran's death. See id. In May 2012, the appellant was notified about how VA assigns disability ratings and effective dates. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). She had an opportunity to present additional evidence in light of this notice prior to subsequent adjudication by the agency of original jurisdiction (AOJ) in October 2012. This course of corrective action fulfills VA's notice requirements. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The Board also finds that the February 2009 notice letter substantially satisfied 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)). The February 2009 letter informed her that VA was responsible for obtaining records from any Federal agency and would make reasonable efforts to obtain evidence from non-Federal custodians. She was invited to submit any evidence in her possession. A remand for further notification of how to substantiate the claim is not necessary. There is no indication that any additional action is needed to comply with the duty to assist. The pertinent VA treatment records have been obtained and associated with the claims file. A January 2008 private medical opinion is of record. VA medical opinions addressing all pertinent theories of entitlement were obtained in May 2010, July and November 2011, and June 2012. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The November 2011 VA reviewer expressed an equivocal opinion on the relationship between herbicide or chemical exposure and pancreatic cancer. The Court has held that the fact that a medical opinion is inconclusive does not by itself render it inadequate for rating purposes. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). However, it must be based upon a fully informed review of the record after consideration of all available evidence. Id. Review of the November 2011 opinion reveals that the examiner carefully considered several clinical studies in light of the Veteran's history, but could not find sufficient evidence to support an etiology. She did not refer to any outstanding medical records. The VA reviewer provided an adequate explanation for reaching an equivocal opinion. Overall, the November 2011 VA medical opinion is adequate for adjudication purposes in light of Jones, supra. In November 2012, the appellant asserted that the June 2012 medical opinion was inadequate. Specifically, it was argued that the reviewer failed to consider whether schizophrenia caused the Veteran's substance abuse problems and the reviewer questioned the Veteran's veracity. Review of the June 2012 medical opinion shows that the examiner reviewed claims file and carefully considered the pertinent evidence. His opinion is consistent with the record and plausible, including his reasons for questioning the Veteran's veracity. The representative also argues that the medical opinion is inadequate because the reviewer failed to examine the relationship between additional psychiatric diagnoses and alcohol abuse and did not answer the questions regarding the relationship between alcohol abuse, pancreatitis, and pancreatic cancer. As noted in the introduction, the Board had determined that service connection is warranted only for schizophrenia. Service connection has been denied for posttraumatic stress disorder (PTSD), depression, and anxiety. Hence, the examiner's failure to consider non-service related diagnoses is inconsequential. The overwhelming medical evidence indicates that pancreatitis was related to alcohol abuse. (See VA treatment records from March to July 2008 referencing alcohol induced pancreatitis). The examiner determined that the schizophrenia symptoms were minimal and not related to alcohol consumption. Thus, his omission of an opinion on whether alcohol induced pancreatitis caused pancreatic cancer is inconsequential. For these reasons, the Board finds the objections to the June 2012 VA medical opinion to be without merit. See id. The Veteran's service treatment records (STRs) are not available. As discussed below, significant efforts were made to locate the STRs without success. (When a claimant's treatment records are lost or destroyed, the VA has a "heightened" duty to assist in the development of the claim. See Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005).) As discussed in its May 2011 remand, the AOJ issued a formal finding on the unavailability of the Veteran's STRs in January 2010. The Board indicated, however, that the record did not contain a response to a records request from the United States Army Enlisted Records & Evaluation Center (USAEREC) at Fort Benjamin Harrison, Indiana. The Board instructed that on remand, the AOJ was to contact the USAEREC in an attempt to secure the Veteran's complete STRs. A July 2011 report of contact shows that the US Army Human Resources Command (HRC) was contacted and it was verified that USAEREC had merged with HRC. The HRC representative was asked to search for STRs pertaining to the Veteran, but responded that no such records existed at that location due to the fact that they were transferred to the National Personnel Records Center (NPRC) following the Veteran's period of active service. As discussed in the May 2011 remand, the NPRC had previously responded to a records request, stating that the Veteran's medical records were not on file, noting that the only medical document on file was the RAD (release from active duty) examination. In response to an April 2003 electronic request for the Veteran's entire personnel file, the NPRC indicated that it had conducted an extensive and thorough search of its records, but was unable to locate the identified records. The NPRC concluded that the requested records either did not exist, that the NPRC did not have them, or that further efforts to locate them at NPRC would be futile. Also as part of its May 2011 remand, the Board instructed the AOJ to attempt to verify the Veteran's dates of service for his period of service beginning with re-enlistment on July 5, 1971, stating that the record raised a question as to the Veteran's service dates. On remand, the AOJ contacted the NPRC, which responded by stating that records show that the Veteran re-enlisted on July 5, 1971, but that the records for that period of service were not on file. The NPRC stated that it could only verify the Veteran's first period of service. The May 2012 remand instructed the AOJ to obtain a VA psychiatric opinion on whether service-connected schizophrenia exacerbated the Veteran's alcohol abuse, whether alcohol abuse caused or made worse pancreatitis, and whether pancreatitis caused or exacerbated pancreatic cancer. A June 2012 medical opinion was obtained; however the examiner did not address the relationship between pancreatitis and alcohol abuse or pancreatitis and pancreatic cancer. Given the overwhelming medical evidence indicating the Veteran had alcohol induced pancreatitis, a relationship between pancreatitis and alcohol abuse is recognized and the omission on this issue is immaterial. (See VA treatment records dated from March to August 2008 showing numerous references to alcohol induced pancreatitis). The June 2012 VA examiner also did not consider whether pancreatitis caused or aggravated pancreatic cancer. Because the Board finds that the Veteran's service-connected schizophrenia is unrelated to alcohol abuse and other service-connected disabilities are unrelated to pancreatitis, the question becomes moot. For these reasons, the June 2012 VA medical opinion substantially complies with the May 2012 remand. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (remand instructions require substantial compliance as opposed to strict compliance). The AOJ readjudicated the issue in the October 2012 supplemental statement of the case. In this case, the Board finds that the actions undertaken by the AOJ satisfy the terms of the Board's May 2011 and 2012 remands. See id.; Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, based on the development undertaken and the negative responses received regarding the availability of the Veteran's STRs, the Board is satisfied that "further efforts to obtain those records would be futile." 38 U.S.C.A. § 5103(b)(3) (West 2002). Accordingly, the Board finds that all available evidence pertaining to the appellant's claim has been obtained. Analysis The appellant is claiming entitlement to service connection for the cause of the Veteran's death. 38 U.S.C.A. § 1310. Service-connected disability will be considered as the principal (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). 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). In determining whether the disability that resulted in the death of the Veteran was the result of active service, the laws and regulations pertaining to basic service connection apply. 38 U.S.C.A. § 1310. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a 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 disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Certain chronic diseases, including malignant tumors, may be presumed to have been incurred in or aggravated by active military service if manifested to a compensable degree within a year of separation from qualifying service. 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For claims filed after October 31, 1990, direct service connection cannot be granted for disabilities resulting from abuse of alcohol or drugs. See 38 U.S.C.A. § 105, 1110 (West 2002); 38 C.F.R. §§ 3.1(n), 3.301 (2012). VA's General Counsel has confirmed that direct service connection for a disability that is a result of a claimant's own abuse of alcohol or drugs is precluded for purposes of all VA benefits for claims filed after October 31, 1990. See VAOPGCREC 7-99 (1999), 64 Fed. Reg. 52,375 (June 9, 1999); VAOPGCREC 2-98 (1998), 63 Fed. Reg. 31, 263 (February 10, 1998). There is an exception to this general rule. In Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the Federal Circuit Court held that compensation could not be awarded pursuant to 38 U.S.C.A. § 1110 and 38 C.F.R. § 105(a) either for a primary alcohol/drug abuse disability incurred during service or for any secondary disability that resulted from primary alcohol/drug abuse during service. Id. at 1376. However, the United States Court of Appeals for the Federal Circuit further held that there can be service connection for compensation for an alcohol/drug abuse disability acquired as secondary to, or as a symptom of, a non-willful misconduct, service-connected disability. In further clarifying this, the Federal Circuit explained that veterans may only recover if they can "adequately establish that their alcohol or drug abuse disability is secondary to or is caused by their primary service-connected disorder." Id at 1381. An award of compensation on such a basis would only result "where there is clear medical evidence establishing that the alcohol or drug abuse disability is indeed caused by a Veteran's primary service-connected disability, and where the alcohol or drug abuse disability is not due to willful wrongdoing." Id. The Federal Circuit has held that "[l]ay 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); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Although a claimant is competent in certain situations to identify a simple condition such as a fall leading to a broken leg, a lay person is generally not competent to provide evidence as to more complex medical questions, such as the etiology of cancer. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. Layno v. Brown, 6 Vet. App. 465, 469 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 U.S.C.A. § 1116(f) (West 2002), 38 C.F.R. § 3.307(a)(6) (iii) (2012). If a Veteran was exposed to an herbicide agent during active military, naval, or air service, certain listed diseases shall be service connected. However, they do not include pancreatic cancer. See 38 U.S.C.A. § 1116 (West 2002), 38 C.F.R. § 3.309(e) (2012). Regardless of whether a claimed disability is recognized under 38 U.S.C.A. § 1116, pertaining to herbicide agent exposure presumptive diseases, 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); McCartt v. West, 12 Vet. App. 164, 167 (1999). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). As noted above, service treatment records are not available. Nevertheless, the appellant does not contend that the Veteran had pancreatic cancer in service or shortly thereafter as the record clearly shows it developed many years after service. However, the record confirms that the Veteran served in Vietnam within the requisite time period to be entitled to a presumption of herbicide exposure. See Veteran's DD 214. It also shows his military occupational specialty (MOS) as a petroleum specialist. VA treatment records from January 1995 document psychiatric treatment. The Veteran complained about depression, nervousness, and sleep disturbance. He acknowledged excessive alcohol use, in addition to cannabis and cocaine use. Behavioral observations showed a depressed and anxious mood. Thought pattern was intact and no hallucinations or delusions were identified. For diagnosis, the examiner listed rule out posttraumatic stress disorder (PTSD) and major depression and noted alcohol and cocaine dependence. The Veteran underwent a VA PTSD examination in June 1995. He reported an intermittent employment history and recently sought inpatient psychiatric treatment. He related a fear of rodents due to his military experience. Mental status examination showed him to be alert, oriented, and cooperative. He had a full affect, normal speech, and neutral mood. His thought process was logical and coherent without evidence of psychosis. The examiner gave a diagnosis of alcohol abuse, history of polysubstance abuse and PTSD traits. The Veteran had another period of inpatient treatment for alcohol and cocaine dependence in April 1997. His chief complaint was depressive episodes. He acknowledged continued excessive alcohol consumption, in addition to crack-cocaine and cannabis abuse. Mental status examination showed a subdued and dysphoric mood. Psychosis was not found. The examiner continued the assessment of alcohol and cocaine dependence. VA treatment records from July 2004 to January 2006 show that the Veteran regularly visited the primary care clinic (PCC). In these records, polysubstance dependence, cocaine dependence, alcohol dependence, and dysthymic disorder are listed as active problems. He was not known or suspected to have diabetes. The Veteran underwent a private psychological assessment in January 2008. Mental status showed the Veteran to present with an appropriate appearance, manner, and speech. He had short-term memory loss and a depressed affect. Motor activity was normal. He described audio hallucinations since the early 1980s. The Beck Depression Inventory score suggested severe depression. He stated that he had seen psychiatrists since service. From the early 1980s, he began experiencing auditory hallucinations. He indicated they were voices encouraging him to commit suicide. He reported using alcohol and drugs to self-medicate. He described in-service stressors and social and occupational difficulties following service. He was unable to complete the entire interview. However, from the interview, the examiners noted symptoms of anxiety, severe depression, sleep disturbances, memory loss, suicide ideation, and substance abuse. The Veteran had high scores for PTSD on two clinical tests. The examiners noted his psychotic symptoms appear to have been an important factor in his service difficulties. He used alcohol and drugs to self-medicate. The examiners observed that it was not clear that his mental health problems were related to in-service stressors or whether psychotic symptoms preexisted service. However, they believed it more likely that the psychotic symptoms preexisted service. They concluded that the Veteran had chronic and persistent schizophrenia, which was exacerbated by service. They believed the Veteran's emotional instability led to the development of PTSD. The severe anxiety symptoms also contributed to his substance abuse disorders. The examiners explained how the Veteran met each PTSD criterion. They concluded with the following diagnoses: schizophrenia, paranoia type, chronic mild; PTSD chronic, secondary to combat stressors; major depression severe with psychotic features, and alcohol dependence, chronic. VA treatment records from March 2008 show that the Veteran underwent an endoscopic retrograde cholangiopancreatography (ERCP). The listed impressions were benign appearing biliary stricture in the bile duct, which was treated with stent placement, and ethanol induced chronic pancreatitis. The Veteran visited the emergency room in April 2008 due to abdominal pain. It was associated with the stent placement. The severe pain last 15 minutes and then subsided. Clinical examination showed abdominal tenderness. The examiner advised complete cessation of alcohol to prevent pancreatitis. He also ordered a CT scan of the liver and appropriate follow-up. VA treatment records from June 2008 show that the Veteran had a plugged biliary stent. He complained about fatigue and tiredness. He underwent another ERCP. Based upon these findings, a biopsy was taken of a biliary stricture. CT scan of the abdomen showed a "vaguely lucency" suggesting possible cancer. About a week later, the biopsy results confirmed pancreatic cancer. The Veteran had surgical consultation for possible Whipple procedure. In June 2008, the Veteran had a VA diabetes examination. The examiner noted a diagnosis of diabetes secondary to pancreatic cancer. Clinical examination was remarkable for lower extremity neuropathy. The Veteran was scheduled for a Whipple procedure in July 2008. Upon pre-surgical evaluation, cardiac problems were noted. He had 95 percent stenosis of the right coronary artery. Because of perioperative cardiac risk, he declined the Whipple procedure. However, a laparoscopy was performed. The post operative diagnosis was biopsy proven peritoneal metastases from known pancreatic adenocarcinoma. VA treatment records from August 2008 show that the Veteran was informed about the option of chemotherapy and hospice care. However, the examiner advised that his cancer was incurable and any treatment would only be palliative. In September and October 2008, the Veteran had a course of chemotherapy treatment. The Veteran died in January 2009. On his death certificate, the immediate cause of death was metastatic pancreatic cancer. No contributing causes were given. In March 2009, the appellant reported that she met the Veteran in 2006 and married him in October 2007. She observed his psychiatric symptoms including depression, flashbacks, phobias, and sleep disturbances. She acknowledged the Veteran smoked and drank heavily. She often worried about his behavioral problems and substance abuse issues. In her June 2009 notice of disagreement, the appellant advanced several theories of entitlement. She believed Agent Orange exposure and a mental condition contributed to pancreatic cancer. Also, she asserted the Veteran had long-standing diabetes that had not been diagnosed, which also contributed to the cancer. In September 2009, the appellant reported that she believed the Veteran had diabetes prior the formal diagnosis of pancreatic cancer and his diabetes was a contributing factor in developing pancreatic cancer. In May 2010, VA obtained a medical opinion. The examiner reviewed the claims folder and expressed a negative opinion regarding diabetes as a cause. He stated that diabetes mellitus had many causes, but the underlying cause was a decrease in insulin production by the pancreas. However, diabetes does not cause pancreatic problems. He noted there is also no medical evidence showing that pancreatitis or pancreatic cancer was related to Agent Orange exposure. In October 2010, the appellant submitted several medical articles. They included published articles about jet fuel, insecticide use for "Operation Flyswatter" in Vietnam, an article on pesticides, mosquito control activity by the military in Vietnam, and pesticides and chronic illness. She also submitted an article on PTSD and Substance Use Disorders. It noted a significantly increased incidence of substance use, abuse, and dependency among Veterans with PTSD. Two articles pertained to pancreatic cancer. One article reported that pancreatic cancer is almost always fatal. Surgical intervention is opted in only 15 to 20 percent of cases, but prognosis remained poor. Notably, one article listed industrial chemicals as causes and predisposing factors of pancreatitis, diabetes, and chronic alcohol abuse. Another two articles detailed military life in Vietnam. The appellant had a hearing in October 2010. She contended that the Veteran used tobacco and drank heavily due to service-related psychiatric problems. She also asserted that service-connected diabetes substantially contributed to pancreatic cancer and chemical exposure in Vietnam was related to the development of pancreatic cancer. She argued that service-connected heart disease was another contributing factor as it prevented him from undergoing operative treatment (Whipple procedure). She reported that the Veteran had diabetes for many years. She also recalled that the Veteran told her he worked with jet fuel in service. In July 2011, a VA cardiac medical opinion was obtained. The examiner reviewed the claims folder and expressed a negative opinion. He noted that the July 2008 laparoscopy confirmed that the cancer was metastatic. Hence, even if the Whipple procedure had been performed, it would not be effective as the cancer was metastatic. He stated that ischemic heart disease played no role in the pathogenesis of pancreatic adenocarcinoma. In November 2011, a VA substance/ chemical medical opinion was obtained. The examiner reviewed the claims folder. She stated that she could not find a link between pancreatic cancer and any substance/ chemical exposure without resort to speculation. She noted that the Veteran's occupational specialty would put him into contact with fuel and related chemicals. Medical studies have shown a relationship between benzene and hematogenous cancers and between smoking and pancreatic cancer. She cited several medical articles in support of her opinion. A VA psychiatric opinion was obtained in November 2011. The examiner reviewed the claims folder and noted the pertinent psychiatric treatment history. He declined to diagnose PTSD. He stated that the Veteran's reported stressor of rodent phobia did not meet criterion A of a life-threatening stressor. The January 2008 private assessment was the only time the Veteran had been diagnosed with PTSD or schizophrenia. However, there was no prior evidence of psychotic symptoms to support such diagnoses. He believed the severe inconsistencies in symptoms reported at the January 2008 evaluation with the prior evidence raised credibility issues. He observed that a validity score of a quantitative assessment given in January 2008 was not listed. For these reasons, he believed clinical treatment records were more probative than the January 2008 private evaluation. Clinical records documented severe substance abuse problems and mood problems. The appellant had another hearing in March 2012. She recalled that the Veteran was diagnosed with diabetes when they were married in 2007. He started to lose weight and was subsequently diagnosed with pancreatic cancer. He could not have Whipple surgery due to a newly discovered heart condition. His physician informed her that the surgery would have likely prolonged his life for many years. After he declined the Whipple surgery, his health deteriorated very quickly. In June 2012, VA contacted the November 2011 psychiatric examiner for another medical opinion. The examiner re-reviewed the claims folder and recited the pertinent clinical evidence. He opined that it was less likely that the Veteran's alcohol abuse was caused by or chronically made worse by service-connected schizophrenia. He stated that the only record of a schizophrenia diagnosis was at the January 2008 private medical evaluation. There was no significant clinical evidence that the Veteran was otherwise treated for schizophrenia. On numerous occasions, he denied having psychotic-type symptoms. The reviewer stated that the symptoms of schizophrenia were not subtle, but rather obvious, and would have been recognized upon instances of treatment for substance abuse. In November 2012, the Veteran's representative submitted a statement summarizing the appellant's contentions. She reiterated that the Veteran's psychiatric problems led to chronic substance abuse. It was also argued that the Veteran had made poor lifestyle decisions of smoking and not exercising due to his psychiatric problems. In April 2013, Dr. A.G. submitted a medical opinion. She reviewed the claims folder and recited the pertinent medical history. She stated that the exact cause of pancreatic cancer was unknown, but smoking and age were major risk factors, among others. She stated that diabetes had been linked to pancreatic cancer. She noted that diabetes was also a symptom of pancreatic cancer and long standing diabetes may increase the risk of pancreatic cancer. She discussed several medical studies about the relationship between pancreatic cancer and diabetes. A medical study stated that pancreatic cancer is only diagnosed in late stages and persons with chronic pancreatitis needed systemic observation. She suggested that the immune suppressing qualities of diabetes would increase cancer risk as cancer manifested itself on weakened immune systems. Dr. A.G. concluded that the Veteran had alcohol abuse problems and was diagnosed with alcohol-induced pancreatitis, which is a risk factor for pancreatic cancer. She also noted that clinical studies have revealed a high degree of overlap between schizophrenia and addictive disorders. She believed there was often a cyclical causative relationship with chronic substance abuse and mood symptoms. Thus, it was more likely than not that the Veteran's alcohol dependence was exacerbated by schizophrenia. She also asserted that it was at least as likely as not that the Veteran's diabetes contributed to the development of pancreatic cancer. She cited to the immune-suppressive nature of diabetes. As discussed above, the Veteran's service treatment records are not available and are presumed lost. Extensive efforts were made by VA to obtain these records, with no success. The Board notes that VA has heightened duties when the Veteran's service treatment records have been destroyed. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). However, the case law does not establish a heightened benefit-of-the-doubt standard, only a heightened duty of the Board to consider applicability of the benefit-of-the-doubt doctrine, to assist the claimant in developing the claim, and to explain its decision. See Cromer v. Nicholson, 19 Vet. App. 215 (2005). The Veteran had the following service-connected disabilities: schizophrenia, 70 percent disabling; right coronary artery stenosis, 60 percent disabling; diabetes mellitus, 20 percent disabling; and peripheral neuropathy of left and right lower extremities, each rated as 10 percent disabling. He died in January 2009. On his death certificate, the immediate cause of death was metastatic pancreatic cancer. No other causes were noted. The appellant contends that service-connected disabilities were a contributing cause to the Veteran's development of pancreatic cancer. She has advanced several theories of entitlement, which will be examined in detail below. As an initial matter, the Board notes that the appellant and the Veteran were competent to describe symptoms readily capable of lay observation, to include recollections of medical diagnoses or information given by treating clinicians. See Layno, 6 Vet. App. at 469; see Jandreau, 492 F.3d at 1377. However, determining whether the development of pancreatic cancer is related to service-connected disabilities is a medical question. The appellant is not shown to be a medical professional, and she is not competent to express an opinion on such issues. See Woehlaert, 21 Vet. App. 456; see also Waters, 601 F.3d 1274. Thus, her assertions are not competent evidence to show a nexus to service and in this regard, have no probative value. Id; see Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. The record includes numerous competent medical opinions on the etiological relationship between specific service-connected disabilities and pancreatic cancer. By "competent medical evidence" is meant in part that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). In cases of conflicting medical opinions, the Board must analyze the credibility and probative value, account for evidence that it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the Veteran. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on factors such as reasoning employed by the medical professionals, and whether or not and to what extent they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 336 (1994). The appellant contends that the Veteran's service-connected heart disease was a contributing cause in the Veteran's development of pancreatic cancer. The Veteran was unable to have Whipple surgery shortly after his cancer diagnosis due to his heart condition. A July 2011 VA medical opinion is of record. The examiner expressed a negative opinion. He explained that the Whipple procedure would not have cured the cancer because it had already metastasized by the time of the proposed surgery. He also noted that there is no etiological relationship between ischemic heart disease and pancreatic cancer. The opinion is consistent with July 2008 VA clinical records and is accompanied by a plausible rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2009); Barr, 21 Vet. App. 303; see Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board considers the July 2011 VA medical opinion to be probative and weigh against any claim that service-connected heart disease substantially contributed to the Veteran's death. Briefly, the Board notes that the appellant reported that a physician had informed her that the Whipple procedure would be highly beneficial and curative. See October 2010 hearing transcript. She is competent to relate information given to her by physicians as competent medical evidence. See Layno, 6 Vet. App. at 469. However, her report is inconsistent with the June and July 2008 VA treatment records, which do not include any such statements by healthcare providers. The Board does not consider her report credible. Caluza, 7 Vet. App. at 510-511. Further, the Board observes that a pancreatic cancer medical article submitted by the appellant concludes that the prognosis is generally poor for pancreatic cancer patients even with surgical intervention. For the foregoing reasons, the Board finds the weight of the evidence is against the appellant's contention that service-connected heart disease had any relationship to the development of pancreatic cancer or the Veteran's demise. As noted above, the Veteran is presumed to have been exposure to herbicides during service. See DD 214; 38 C.F.R. § 3.307(a)(6)(iii). The Board also accepts the appellant's report that the Veteran was likely exposed to industrial chemicals as his MOS was as a fuel technician. Pancreatic cancer is not a disease presumptively related to herbicide exposure. 38 C.F.R. §§ 3.307, 3.309. The Secretary of the Department of Veterans Affairs has determined that a presumption of service connection based on exposure to herbicides is not warranted for hepatobiliary cancers, including pancreatic cancers. See Notice, 75 Fed. Reg. 32540 -32548 (June 8, 2010). Nevertheless, the Board will consider whether there is a direct relationship to herbicide exposure. Combee, 34 F.3d at 1044-45. The August 2011 examiner expressed an equivocal opinion after consideration of all pertinent evidence, including reports of jet fuel chemical exposure. She cited several medical articles to support her opinion. The August 2011 VA medical opinion is not dispositive, particularly in light of the assessments that alcohol and tobacco use were major risk factors for the development of cancer. See id.; Jones, 23 Vet. App. at 389. Nevertheless, service connection may not be based on resort to speculation or remote possibility. 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). It has also been observed that statements from doctors that are inconclusive as to the origin of a disease cannot be employed as suggestive of a linkage between the current disorder and the claimed incident of military service. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 140, 145-6 (1993). Hence, the August 2011 VA medical opinion does not provide a basis on which service connection may be granted. The Board notes that the appellant submitted various medical articles about pesticide and other chemicals used in Vietnam. 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); see also Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor's statements was "adequate to meet the threshold test of plausibility"). However, these medical studies would not include consideration of the additional pancreatic cancer risk factors, namely alcohol and tobacco use, exhibited by the Veteran. Thus, the Board considers them too generic to support the claim in light of the particular facts surrounding it. Id.; Sacks v. West, 11 Vet. App. 314, 317 (1998) (holding that a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). As for the contention that diabetes played a role in the Veteran's demise, the May 2010 VA examiner expressed a negative opinion on the relationship between diabetes and pancreatic cancer. His assessment was based upon review of the claims folder and clinical knowledge. He noted that the Veteran was not assessed as having diabetes until he developed alcohol induced pancreatitis. He believed it was more likely that pancreatitis caused the Veteran to develop diabetes. He explained that the underlying cause of diabetes is decreased insulin production by the pancreas. Hence, pancreas dysfunction causes diabetes. However, the converse was not shown--diabetes causing pancreatic problems. The May 2010 VA medical opinion was based upon an accurate review of the record and is plausible. Nieves-Rodriguez, 22 Vet. App. at 304; Barr, 21 Vet. App. 303. The Board considers it persuasive. The April 2013 opinion by Dr. A.G. supports the appellant's contention. She concedes that the precise cause of pancreatic cancer is unknown. However, medical studies showed a relationship between long-term diabetes and increased pancreatic cancer. She also reported that the immune suppressing qualities of diabetes would increase the likelihood of cancer. Here, the Veteran is not shown to have diabetes until he developed pancreatitis in March 2008. Review of prior primary care records do not include complaints of associated symptoms such as increase thirst or frequent urination among others. Nor do clinicians make any remarks for suspicion of diabetes. Thus, the Veteran was not shown to have had long-standing diabetes, so the clinical studies cited by Dr. A.G. make her rationale less plausible in this case. Nieves-Rodriguez, 22 Vet. App. at 304; Barr, 21 Vet. App. 303. Overall, the Board finds that the May 2010 VA examiner opinion more closely comports with the medical evidence showing late onset of diabetes. The May 2010 VA medical opinion is more consistent with the remainder of the record and thus has greater probative value. Gabrielson, 7 Vet. App. 336; Nieves-Rodriguez, 22 Vet. App. at 304; see VA treatment records March to August 2008. Accordingly, the preponderance of the evidence is against the claim of that diabetes caused or worsened pancreatic cancer. Lastly, the appellant contends that service-connected schizophrenia materially or substantially contributed to the Veteran's development of pancreatic cancer by increasing his propensity to abuse alcohol, which in turn led to pancreatitis. VA treatment records since March 2008 include multiple assessments of alcohol induced pancreatitis with subsequent development of metastatic pancreatic cancer. Prior VA treatment records document a long-standing history of alcohol abuse. Overall, the evidence shows that the Veteran's development of pancreatitis was likely related to his extensive history of alcohol abuse. In addition to schizophrenia, the Veteran had been diagnosed with additional psychiatric disorders of depression, anxiety, and PTSD. The Board considered these additional psychiatric disorders in May 2012 and found that they were not related to service. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Hence, the Board must consider whether schizophrenia alone caused or aggravated the Veteran's alcohol abuse to the extent where it would have materially or substantially contributed to his development of pancreatitis, which is a risk factor for pancreatic cancer. Allen, 237 F.3d at 1376; 38 C.F.R. § 3.312. In instances where the evidence is indistinguishable regarding the symptoms of a service-connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). In June 2012, a VA examiner expressed a negative opinion on whether the Veteran's chronic alcohol abuse was caused by or chronically worsened by schizophrenia. He reviewed the claims folder and explained that the clinical records did not document significant schizophrenia symptoms to promote alcohol abuse. He explained that schizophrenia symptoms are highly recognizable and if present, would have been reported during clinical treatment. The Board notes that the Veteran sought psychiatric attention for substance abuse on several occasions and it would be expected that psychosis, PTSD, or other schizophrenia symptoms would be recorded in clinical records. Review of substance abuse treatment records from the 1990s and more recent non-psychiatric records do not contain any complaints or findings for schizophrenia or psychotic type symptoms based upon clinical observation and direct query. (See VA treatment records from January 1995, April 1997, July 2004 to January 2006, and March to September 2008). Hence, the June 2012 examiner's explanation that the Veteran did not display significant schizophrenia symptoms is consistent with the record. That the Veteran had minimal symptoms due to schizophrenia is consistent with the fact that the treating VA clinicians had declined to provide a schizophrenia diagnosis. See id. The June 2012 examiner indicates that schizophrenia symptoms are distinguishable from mood or substance abuse disorders and does not suggest non-service connected mood disorders are in any way related to schizophrenia. Mittleider, 11 Vet. App. 181, 182. For these reasons, the Board considers the June 2012 medical opinion to be probative and weigh against the claim. Nieves-Rodriguez, 22 Vet. App. at 304; Barr, 21 Vet. App. 303. Briefly, the Board observes that, in November 2011, the same VA psychiatric examiner had also questioned the Veteran's veracity in reporting symptoms in January 2008. The Veteran's reports were then used by the January 2008 clinicians to make PTSD and schizophrenia diagnoses. The basis for the VA examiner's low credibility assessment was inconsistency with reports and findings from prior clinical records, as opposed to lack of medical treatment. Hence, the November 2011 examiner's assessment that the Veteran was not likely credible is probative. Caluza, 7 Vet. App. at 510-511; Buchanan, 451 F.3d at 1337. The private January 2008 evaluation supports the claim. The examiners concluded that the Veteran's "severe anxiety-based" conditions, identified as schizophrenia and PTSD, contributed to his alcohol abuse. Allen, 237 F.3d at 1376. They do not discuss the absence of schizophrenia symptoms or schizophrenia assessments by treating clinicians in prior clinical records. Further, they describe the schizophrenia symptoms as "mild" in their diagnosis. The April 2013 medical opinion by Dr. A.G. also supports the claim. She based her opinion on clinical evidence showing an increased incidence of substance abuse for schizophrenics. Similar to the January 2008 examiners, she does not discuss the absence of schizophrenia symptoms or schizophrenia assessments by treating clinicians in prior clinical records. For these reasons, the Board finds Dr. A.G.'s April 2013 opinion to be less persuasive with regard to the effect that schizophrenia had on alcohol abuse. Id. In summary, the Board finds the June 2012 VA medical opinion to be the most persuasive as it addresses inconsistencies in the record; whereas the January 2008 and April 2013 medical opinions do not. The June 2012 opinion is also more plausible in light of the entire clinical record. The Board considers it to be highly unlikely that numerous treating clinicians over a significant time period would completely fail to identify schizophrenia symptoms. This strongly suggests that the Veteran's schizophrenia was mild and had no effect on his drinking problem. In other words, the complete absence of schizophrenia assessments in prior clinical records undermines the plausibility of the January 2008 and April 2013 assessments that the Veteran's schizophrenia was severe enough to cause the alcohol abuse. For these reasons, the Board assigns greater probative value to the notion articulated by the VA examiner that alcohol abuse was not exacerbated by service-connected schizophrenia. Gabrielson, 7 Vet. App. 336; Nieves-Rodriguez, 22 Vet. App. at 304; Allen, 237 F.3d at 1376 For the foregoing reasons, the preponderance of the evidence is against the appellant's claim. The benefit-of-the-doubt doctrine is therefore not helpful to the claimant, and the claim for service connection for the cause of the Veteran's death is denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. (CONTINUED ON NEXT PAGE) ORDER 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