Citation Nr: 1317610 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 10-43 997 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Nicholas A. Sarokhanian, Attorney at Law WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD M. Donohue, Counsel INTRODUCTION The Veteran served on active duty from November 1952 to June 1953 and from December 1954 to December 1974. He died in January 2009. The appellant claims as the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office in Waco, Texas. In August 2010, the appellant presented testimony at a personal hearing conducted at the RO before a Decision Review Officer (DRO). In February 2012, she testified at a personal hearing which was chaired by the undersigned Veterans Law Judge at the Board's offices in Washington D.C. Transcripts of these hearings have been associated with the Veteran's VA claims file. The appellant has completed a VA Form 21-22a, Appointment of Individual as Claimant's Representative, for the attorney listed on the cover page. She has also completed a VA Form 21-22a which appoints James H. Voelker, Attorney at Law, as her representative. In a July 2011 letter, Mr. Voelker clarified that Mr. Sarokhanian would act as the lead attorney for the appellant. VA regulations provide that only one attorney will be recognized at one time in the prosecution of a particular claim. 38 C.F.R. § 14.631(e)(1) (2012). The Board notes, however, that VA regulations also provide that "if the claimant consents in writing, an attorney associated or affiliated with the claimant's attorney of record or employed by the same legal services office as the attorney of record may assist in the representation of the claimant." 38 C.F.R. § 14.629(c)(2). As the record reflects that both Mr. Voelker and Mr. Sarokhanian work in the same legal agency, and the appellant has completed an authorization form for Mr. Volker, the Board finds that he may assist in representing the appellant. For purposes of this appeal, however, only Mr. Sarokhanian will be recognized as the attorney for the appellant. In June 2012, the Board requested a medical opinion from the Veterans Health Administration (VHA) in order to address whether the Veteran's renal cell carcinoma was caused by exposure to herbicides or by his service-connected Hodgkin's lymphoma or the chemotherapy treatment therefore. See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901(d) (2012). The requested opinion was received by the Board in August 2012. On August 21, 2012, the Board wrote to the appellant, provided her a copy of the VHA opinion, and solicited additional evidence and/or argument. Cf. Thurber v. Brown, 5 Vet.App. 119 (1993). She subsequently provided additional argument and evidence. As noted, the appellant has submitted additional evidence and argument directly to the Board. While the RO has not considered this evidence, the appellant waived consideration of such evidence by the agency of original jurisdiction in a February 2013 signed statement. See 38 C.F.R. § 20.1304 (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). FINDINGS OF FACT 1. At the time of his death, the Veteran was in receipt of service connection for Hodgkin's disease, rated as noncompensable (zero percent disabling). 2. The Veteran's death certificate shows that he died in January 2009 at age 75. The immediate cause of death was listed as metastatic renal cell carcinoma. No diseases, injuries or complications leading to the immediate cause of death or as another significant condition contributing to death but not resulting in the underlying cause were listed. 3. Renal cell carcinoma did not manifest during service or within one year of the Veteran's separation from service, and is not attributable to his active duty service. 4. A service-connected disability did not influence the Veteran's death. CONCLUSION OF LAW The requirements for service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1154, 1310, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION After the evidence has been assembled, the Board is responsible for evaluating the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). Indeed, in Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet.App. 518, 519 (1996), citing Gilbert, 1 Vet.App. at 54. Furthermore, the Board notes that it has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the issue adjudicated herein and what the evidence in the claims file shows, or fails to show, with respect to this claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet.App. 122, 128-30 (2000). I. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The law and regulations also require VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. Upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The United States Court of Appeals for Veterans Claims (Court) held in Hupp v. Nicholson, 21 Vet. App. 342 (2007), that additional notice requirements apply in the context of a claim for Dependency Indemnity and Compensation (DIC) benefits based on service connection for the cause of death. In particular, 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. The Court stated that the content of the notice letter will depend upon the information provided in the claimant's application and that the letter should be "tailored" to be responsive to the details of the application submitted. While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a predecisional adjudication of the claim prior to providing compliant notice. In this case, the appellant was provided a notice letter in August 2009, prior to the initial decision on the claim in September 2009. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the requirements with respect to the content of the notice were met in this case. The RO informed the appellant in the August 2009 letter that service connection for Hodgkin's disease was in effect at the time of the Veteran's death. The letter also informed her of what the evidence must show to support a death claim based on this previously service-connected condition as well as an explanation of the evidence and information required to substantiate a claim based on a condition not yet service-connected. The August 2009 letter also notified the appellant of the division of responsibilities in obtaining the evidence. With respect to the notice requirements set forth in Dingess and the appellant's cause of death claim, elements (1) and (2), veteran status and his death are not at issue. Moreover, elements (4) and (5), degree of disability and effective date, are rendered moot via the Board's denial of the claim on appeal. In other words, any lack advisement as to those two elements is meaningless, because a disability rating and effective date are not assigned. The appellant's claim is being denied based on element (3), a connection between the Veteran's service and his death. As explained above, she has received proper notice as to her obligations and those of VA, with respect to this crucial element in the above-mentioned VCAA letter which informed her of what the evidence must show. In short, the record indicates that the appellant received appropriate notice pursuant to VCAA. The VCAA also provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. In the present appeal, the Board finds that reasonable efforts have been made to assist the appellant in obtaining evidence necessary to substantiate her claim, and that there is no reasonable possibility that further assistance would aid in substantiating it. In particular, the record contains the Veteran's service treatment records, private medical records, VA medical opinions, a VHA opinion, medical opinions and treatise articles submitted by the appellant and a copy of the Veteran's death certificate. The Board has carefully reviewed the appellant's statements and concludes that she has not identified further evidence not already of record. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the appellant's claim. As the Board will discuss in its analysis, the RO obtained a VA medical opinion in October 2008 - prior to the Veteran's death - in connection with his then pending claim of entitlement to service connection for renal cell carcinoma. This medical opinion reflects that the VA examiner reviewed the Veteran's past medical history and rendered an appropriate opinion which was supported by reasons and bases. See Barr v. Nicholson, 21 Vet.App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet.App. 295 (2008). During the current appeal, the RO obtained an additional medical opinion from the examiner who provided the above-mentioned October 2008 report. In this September 2010 opinion, the VA examiner stated that he reviewed the Veteran's past medical history, reviewed medical literature with a staff-oncologist, and provided an opinion which was supported by reasons and bases. In June 2012, the Board noted that the appellant had submitted additional medical articles following the October 2008 and September 2010 medical opinions and requested a VHA opinion. A report dated in July 2012 was subsequently obtained. A review of the July 2012 VHA opinion reflects that the physician reviewed the Veteran's medical history and the claims file, including his service treatment records, post-service medical records, death certificate, and the contentions of the appellant. She considered all of the pertinent evidence of record and provided a complete rationale for opinion cited, relying on and citing to the records reviewed. In December 2011, the appellant argued that the October 2008 and September 2010 VA opinions were inadequate because the examiner did not "cite or otherwise describe in sufficient detail [the] medical literature supporting [his] conclusions." It was also argued that both opinions "rely on general conclusions rather than [an] analysis of the facts specific" to the Veteran. With respect to the appellant's first argument, that the VA opinions are inadequate because the examiner made "a bare reference to 'medical literature' generally," upon review, the Board is unaware of any regulation or case law which provides that an examiner must include citations to applicable medical literature. In fact, the Court has recently stated that "there is no reasons or bases requirement imposed on [VA] examiners. Rather, an adequate medical report must rest on correct facts and reasoned medical judgment so as inform the Board on a medical question and facilitate the Board's consideration and weighing of the report against any contrary reports." See Acevedo v. Shinseki, 25 Vet.App. 286, 294 (2012). The Court has also recently stated that "examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." See Monzingo v. Shinseki, 26 Vet.App. 97 (2012); citing D'Aries v. Peake, 22 Vet.App. 97, 104 (2008) ("An opinion is adequate where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's 'evaluation will be a fully informed one.") In support of her argument that the VA examiner's opinions were insufficient because the examiner failed to provide appropriate citations, the appellant has relied on the Court's decisions in Fallo v. Derwinski, 1 Vet.App. 175 (1991) and Hatlestad v. Derwinski, 3 Vet.App. 213 (1992). While the Board disputes that these cases stand for the proposition that VA examiners must cite to any medical textbook, treatise or case study which they relied upon in forming an opinion, a detailed analysis is not required as such cases would have been reversed by the Court's decision in Acevedo and Monzingo as discussed above. The appellant's second argument - that both VA opinions rely on general conclusions rather than an analysis of the facts and are therefore inadequate - is equ ally unpersuasive. Upon review, the appellant argues that although the examiner reviewed the Veteran's claims file, his conclusion that "there is known to be an increase in solid tumors after treatment for Hodgkin's . . . there is no increase in the rate of renal cell carcinoma as a result of treatment for Hodgkin's disease" is a generalization rather than a conclusion based on a test result, observation or fact specific to the Veteran's case. Upon review, the Board disagrees. The VA examiner's is not a generalization, but the application of a medical principle to the facts in the Veteran's case. While the appellant argues that the VA examiner did not discuss the Veteran's age at the time of his treatment, his treatment regime or several other facts the appellant deemed important, the Board notes that a VA examiner need not analyze individual pieces of evidence with the same precision required of the Board. Floyd v. Brown, 9 Vet.App. 88, 93 (1996); Ardison v. Brown, 6 Vet.App. 405, 407-408 (1994); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The appellant's December 2011 brief noted that although the Veteran's fatal renal cancer is not one of the diseases subject to presumptive service connection based on herbicide exposure, service connection may still be warranted without regard to the statutory presumptions if it can be shown that his diagnosed disability is related to his active duty service. As a result, the appellant argued that the September 2010 VA examiner's opinion is inadequate because it did not consider whether there was a relationship between the Veteran's renal cell cancer and his in-service herbicide exposure despite the lack of a presumptive link. Upon review, the Board notes that the VA examiner's opinion was limited to whether the Veteran's service-connected Hodgkin's disease was related to his renal cell cancer. It did not offer any opinion on the relationship, or lack thereof, between herbicide exposure and renal cell carcinoma. The final argument contained in the appellant's December 2011 brief is that the September 2010 VA examiner's conclusion is contradicted by the weight of the medical literature. While this argument relied, in part, on the prior contentions which have been addressed above, the crux of the appellant's contention is that the VA examiner's opinion is inadequate because the appellant did not agree with the treatise articles submitted in favor of the appellant's claim. The Board finds that this is not sufficient ground to find a medical opinion inadequate. As noted above, "examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." See Monzingo, supra. Such is the case here. In the October 2012, third supplemental brief, the appellant argued that the VHA opinion is inadequate because the examiner reached conclusions based on "generalizations drawn from a review of relevant medical literature that appears to be cursory." The appellant also argues that the examiner provided a brief citation to the Veteran's history and did not "go beyond baseless generalizations to address the 'critical question; of whether [the Veteran's] own renal cell carcinoma was caused by his prior exposure to Agent Blue, Agent Orange, or other herbicide agents while serving in Vietnam." Pg. 6. Upon review, the Board notes that the VHA report is based on a review of multiple medical treatise articles and the physician's opinion is supported by supporting rationale with references to evidence contained in the claims folder. There is no indication that the VHA examiner's opinion was based solely on generalizations that were inapplicable to the Veteran. In short, the record contains an October 2008 and September 2010 medical opinions from a VA examiner. The record also includes a July 2012 VHA opinion. The reports of these opinions reflect that the examiners reviewed the Veteran's past medical history and rendered appropriate opinions consistent with the remainder of the evidence of record. Supporting rationale was also provided for the opinions proffered. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board therefore concludes that the medical opinions are adequate for adjudication purposes. See 38 C.F.R. § 4.2 (2012). The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The appellant has been accorded the opportunity to present evidence and argument in support of her claim. She exercised the option of a personal hearing and was afforded one in August 2010 and February 2012 as detailed in the Introduction. During the February 2012 hearing, the undersigned Veterans Law Judge clarified the issue on appeal and explained what the evidence must show to substantiate the appellants claim. The Veterans Law Judge also identified and explained an evidentiary deficit in the appellants claim and suggested the submission of additional evidence to support the appellant's claim. In fact, after identifying such a defect, the Board member specifically stated: "I cannot emphasize how important it is to receive an opinion from someone qualified that basically connects the dots in this case." See the hearing transcript, page 6. In this capacity the record was left open for a sixty-day period following the hearing to allow for the submission of such additional evidence. The actions of the VLJ supplement the VCAA and comply with any related duties owed during a hearing. See 38 C.F.R. § 3.103 (2012). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and that no further development is required to comply with the duty to assist the appellant in developing the facts pertinent to his claim. Essentially, all available evidence that could substantiate the claim has been obtained. There is no indication in the file that there are additional relevant records that have not yet been obtained. II. Law and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including malignant tumors, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. § 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). The death of a veteran will be considered as having been due to a service-connected disability where the evidence establishes that such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). A principal cause of death is one which, singularly 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 is one which contributes substantially or materially to death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). Service-connected disabilities 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 was resulting debilitating effects and general impairment of health to the extent that would render the person less capable of resisting the effects of either disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of co-existing conditions, but, even in such cases, there is for consideration whether there may be reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. 38 C.F.R. § 3.312(c)(4). A Veteran who, during active military, naval, or air service, 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. See 38 C.F.R. § 3.307(a)(6)(iii) (2012). For purposes of presumptive service connection, the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307 (2012). Furthermore, the diseases listed at 38 C.F.R. § 3.309(e) shall, in turn, be presumptively service connected if this requirement is met, even though there is no record of such disease during service. However, renal cell carcinoma is not among the diseases listed at 38 C.F.R. § 3.309(e) and is not subject to a presumption of service connection under § 3.309(e). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), does not preclude establishing entitlement to service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). III. Analysis The appellant contends that the Veteran's death was related to his in-service exposure to herbicides. She has also argued that the Veteran's death was caused by the chemotherapy treatment he received for his service-connected Hodgkin's lymphoma or by the Hodgkin's lymphoma itself. The Veteran's death certificate indicates that his immediate cause of death was metastatic renal cell carcinoma. There are no listed diseases, injures, or complications leading to the immediate cause of death, or as a significant condition contributing to death but not resulting in the underlying cause. At the time of his death service-connected had been established for Hodgkin's lymphoma. A. The Herbicide Exposure Theory With respect to the appellant's argument that the Veteran's renal cell carcinoma is a result of his in-service exposure to herbicides, the record indicates that the Veteran served in the Republic of Vietnam and his exposure to herbicides is therefore presumed. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e) (2012). The Veteran's service treatment records do not indicate that he was treated or diagnosed with renal cell carcinoma during service, and the appellant does not contend otherwise. Rather, examination in October 1970 and October 1973 disclosed that the genitourinary system was normal. Microscopic urinalysis was essentially negative in October 1972. The Veteran denied a history of blood in his urine and/or frequent or painful urination. Moreover, there is no evidence of renal cell carcinoma until July 2003, nearly three decades after the Veteran was discharged from active duty. Accordingly, the presumptive provisions of 38 C.F.R. § 3.309(a) do not apply. Renal cell carcinoma is listed among the herbicide related diseases enumerated in 38 C.F.R. § 3.309(e). As noted above, however, this does not preclude the appellant from establishing service connection for renal cell carcinoma with proof of actual direct causation. See Combee, supra. In this capacity, the Board notes that the record contains September 2008 and January 2010 statements from the Veteran's "principal treating oncologist," E.A., M.D. While these statements discuss the Veteran's in-service exposure to herbicides and Hodgkin's lymphoma, they do not address the etiology of his renal cell carcinoma. In a February 2009 statement, R.W., D.O., stated that he was a primary care provider for the Veteran and that the Veteran "suffer[ed] from Hodgkin's Lymphoma, Diabetes, and Renal Cell Carcinoma. After reviewing his past medical history notes," Dr. R.W. stated that he agreed with Dr. E.A. "that the Veteran's conditions are most probable due to the exposure to Agent Orange." The appellant has also submitted multiple medical treatise articles and Internet articles in support of her claim. Included among the articles is a May 2011 press release from the American Urological Association. This statement reported that "new data from researchers at the Veterans Affairs Medical Center in Shreveport, LA, indicates that there may be a connection between veterans' in-country exposure [to herbicides] and subsequent development of renal cancer." In her third supplemental brief, the appellant also argued that the Veteran was exposed to Agent Blue during service which contains cacodylic acid and this exposure has been shown to cause kidney cancer. See the October 2012 brief, page 2. In support of her argument, the appellant submitted an article titled Arsenic and Arsenic Compounds which indicates that dimethylarscinic acid (which is synonymous with cacodylic acid) is "possibly carcinogenic to humans." See pages 42, 85. In addition, the Board observes that The Agent Orange Act of 1991 requires that when the Secretary determines that a presumption of service connection based on herbicide exposure is not warranted for health outcomes, he must publish a notice of that determination, including an explanation of the scientific basis for the decision. The law requires that the Secretary's determination must be based on consideration of reports of the National Academy of Sciences (NAS) and all other sound medical and scientific information and analysis available to the Secretary. 38 U.S.C.A. § 1116(b) and (c). In September 2011, the NAS issued Veterans and Agent Orange: Update 2010 (Update 2010). The notice was published in the Federal Register and explains a determination made by the Secretary, based upon Update 2010 and prior NAS reports, that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for renal cancer. See 77 Fed.Reg. 47924, 47927 (Aug. 12, 2012). Finally, the Board obtained a VHA medical opinion in July 2012 in order to determine whether a relationship existed between the Veteran's in-service herbicide exposure and his kidney cancer. After reviewing the Veteran's claims file the examiner opined that "it is less likely than not that the Veteran's renal cell carcinoma was caused by exposure to Agent Orange during service." In his opinion, the examiner noted the NAS report which recently found that there was inadequate or insufficient evidence of an association between in-service herbicide exposure and renal cell carcinoma. The examiner further noted the above-mentioned report from the American Urological Association discussing the possible linkage of Agent Orange to Kidney Cancer. However, it was noted that this evidence was not persuasive as the report did not contain a comparison figure to the baseline incidence of kidney cancer "and therefore no conclusions can be made regarding any increased risk due to exposure." The examiner also observed that this report "does not appear to have been published." At this juncture, it is important to note that the Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). However, the Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet.App. 30 (1993), and Colvin v. Derwinski, 1 Vet.App. 171 (1991). In this case, the Board places greater weight of probative value on the VHA expert medical opinion and the findings of the NAS report, than the statement of Dr. R.W. and the medical treatise articles submitted by the appellant. Upon review, unlike the VHA report, Dr. R.W. did not provide any rationale for his conclusion that the Veteran's renal cell carcinoma was related to his in-service herbicide exposure. See Bloom v. West, 12 Vet.App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects 'clinical data or other rationale to support his opinion'); see also Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). In fact, Dr. R.W.'s conclusion that he "agrees with Dr. [E.A.] that [the Veteran's] conditions are . . . due to the exposure to Agent Orange" appears to be based on an inaccurate factual premise since the statements from Dr. E.A. make no such finding. See Monzingo v. Shinseki, 26 Vet.App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely." (citing Reonal v. Brown, 5 Vet.App. 458, 461 (1993))). With respect to the medical treatise evidence and the report from the American Urological Association, the Board notes that medical treatise evidence can, in some circumstances, constitute competent evidence. See Wallin v. West, 11 Vet.App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, the Board finds this evidence to be of little probative value. As noted by the VHA examiner, the findings appear to have been flawed as they did not include a comparison figure of the study's findings to a baseline incidence of kidney cancer and the report was not published. With respect to the Arsenic and Arsenic Compounds article, the appellant relies on this article for the proposition that Agent Blue (a tactical herbicide used in the Republic of Vietnam) contained cacodylic acid (also known as dimethylarsinic acid) which will cause kidney cancer in humans. Upon review, however, the article notes that dimethylarsinic acid is only "possibly carcinogenic to humans." See the Arsenic and Arsenic Compound article, page 85. The use of speculative language, such as 'possibly' is troubling because the Court has held that medical opinions that are speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet.App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). Such is the case here. The Board has also considered the material submitted by the appellant's representative, to include the medical text regarding dioxin exposure and renal cell carcinoma, as well the argument that the Veteran was exposed to Agent Blue which contained arsenic and caused his renal cell carcinoma. The Board notes, however, that, while the terms Agent Orange and herbicide exposure are often used interchangeably, the regulations regarding presumptive exposure refer to herbicides, and are not limited to Agent Orange. Any reference to herbicides would therefore encompass the Veteran's exposure to Agent Blue. In September 2011, the appellant also noted that the Board had previously considered whether there as a direct link between exposure to Agent Orange and renal cell carcinoma and cited to three prior Board decisions. Previous decisions from the Board pertaining to other veterans have no precedential value and are binding only with regard to the specific case decided. See 38 C.F.R. § 20.1303; see also Lynch v. Gober, 11 Vet. App. 22, 27 (1997). Nevertheless, the Board has reviewed the cases submitted by the appellant. In the first opinion, Bd. Vet.App. 1104454 (Feb. 3, 2011), the Board granted service connection for the cause of a veteran's death. In that case, however, the veteran's fatal kidney cancer was the result of environmental toxins which did not include herbicides. As such, the case is not relevant to the issue currently before the Board. In the second opinion, Bd. Vet.App. 0509244 (Mar. 28, 2005) the Board granted service connection for kidney cancer as secondary to herbicide exposure. In this case, however, a veteran had been diagnosed with renal cell carcinoma at age 38 and a medical expert in Anatomic Pathology and Laboratory Medicine who also held a Masters Degree in Air Pollution Toxicology stated that in his 26 years of practice he had never encountered a patient with renal carcinoma at such a young age. It was noted that renal cell carcinomas appear in the sixth and seventh decades of life. (The Veteran in the current appeal was 69 years old when diagnosed with kidney cancer.) The Board observed that the evidence was "mixed" and included an opinion from a "well-qualified oncologist" which was supported by medical literature and a detailed rational which stated that there was "no substantial evidence to support a link between the veteran's renal cell carcinoma" and herbicide exposure. On the other hand, the record included a positive nexus opinion from a scientist recognized as an expert in molecular analysis of cancer. As a result, the Board found that the evidence was at least in equipoise and the veteran's claim was granted. In the present case the record reflects that the Veteran was diagnosed with renal cell carcinoma at age 69. The record also does not contain an opinion from a scientist recognized as an expert in molecular analysis of cancer (or any well-reasoned competent and credible opinion for that matter) that, in this case, the Veteran's renal cell carcinoma was a result of his in-service herbicide exposure. As such, the Board finds that the two cases are dissimilar. In the third case cited by the appellant, Bd. Vet.App. 0315405 (July 10, 2003), the Board granted service connection for renal cell carcinoma based on in-service exposure to herbicides. In that case, the record contained two medical opinions, an August 2001 medical opinion from a private physician who explained that "there was a high degree of certainty that the veteran's renal cell carcinoma was related to his exposure to Agent Orange in Vietnam." The only other competent opinion of record was a March 2003 VHA opinion wherein the examiner reported that she was "unable to state that it was likely or at least as likely as not that the veteran's renal cell carcinoma was related to Agent Orange exposure in Vietnam." Upon review, the third case referenced by the appellant appears to have relied upon a medical opinion which is lacking from the current appeal. Specifically, in that case, a private physician provided an opinion that the veteran's renal cell carcinoma was related to his in-service herbicide exposure. That opinion was also supported by reasons and bases and appears to have described a medical history which would be unique to that veteran. As discussed above, the record in the present appeal contains no such competent and credible opinion. The Board is therefore unable to draw a parallel between that case and current appeal before the Board. Upon review, the Board places greater weight of probative value on the July 2012 VHA opinion which reviewed the evidence submitted by the appellant along with the NHA report and the Veteran's medical history and determined that "it is less likely than not that the Veteran's renal cell carcinoma was caused by exposure to [herbicides] during service." In reaching this conclusion, the Board notes the appellant's sincere belief that the Veteran's death is related to exposure to herbicides. However, her opinion is accorded no greater evidentiary value than that of the private medical opinions and articles. See Jandreau, supra. Her opinion is lacking in specifics and detail and is therefore accorded little probative value. B. The Hodgkin's Lymphoma Theory The appellant contends that the Veteran's renal cell carcinoma was caused by his treatment for Hodgkin's Lymphoma or by the Hodgkin' lymphoma itself. The record reflects that the Veteran was diagnosed with Hodgkin's lymphoma in April 1994. He was treated with chemotherapy and the lymphoma went into remission. The record indicates that there was no recurrence of Hodgkin's lymphoma during the Veteran's lifetime. Service connection was granted for Hodgkin's disease in a December 2008 rating decision. This disability was rated as noncompensable [zero percent disabling] at the time of his death. The record contains multiple medical statements and treatise articles which address whether a relationship exists between the Hodgkin's lymphoma and renal cell carcinoma. As an initial matter, the Board notes that the September 2008 and January 2010 statements from Dr. E.A. do not address etiology of the Veteran's fatal renal cell carcinoma. Similarly, Dr. R.W. did not opine on the relationship between the Veteran's kidney cancer and his service-connected Hodgkin's lymphoma. In an October 2008 medical opinion, a VA examiner reported that "there is known to be an increase in solid tumors after treatment for Hodgkin's; however, there is no increase in the rate of renal cell carcinoma as a result of the Hodgkin's disease." As a result, the examiner stated that the Veteran's renal cell carcinoma was "less likely than not due to his Hodgkin's disease." It was noted that the examiner reviewed the Veteran's claims file and current medical literature in forming his opinion. In September 2010, the same VA examiner issued an additional medical opinion. In this report, the examiner noted that he had reviewed the Veteran's claims file again, consulted with a staff oncologist at the VA Medical Center, and had reviewed appropriate medical literature. In this report the examiner noted that "there is no evidence of any increase in renal cell carcinoma due to treatment for Hodgkin's disease." While it was noted that there "is an increased coexistence of renal cell carcinoma and Hodgkin's lymphoma" the etiology of this coexistence has not been determined although it is believed that the two diseases share a common genetic link. In this case, however, the examiner stated that the two diseases did not coexist as the Veteran's lymphoma had been in remission for many years prior to the development of renal cell carcinoma and "it is less likely than not that it affected his ability to combat the renal cancer." It was also noted that the VA examiner, and the staff oncologist he consulted with, believed that "it is less likely than not that the Veteran's service-connected Hodgkin's disease . . . was a contributing factor to his death by metastatic renal cell carcinoma." During the August 2010 DRO hearing, the appellant's witness, Dr. B.M. noted that the Veteran's treating physicians told him that he "would have future cancers" and opined that chemotherapy and other treatment compromised the Veteran's immune system and made him susceptible to future cancer. See the Transcript, page 4. Dr. B.M. indicated that he was speculating because he did not have the records or lab studies. Id. Additionally, Dr. B.M., testified that the medical literature indicated a higher concurrence of renal cell carcinoma and non-Hodgkin's lymphoma. However, he also acknowledged that the literature is unclear as to a cause for this pattern. Dr. B.M. also stated that the fact that the Veteran had one of the rarest forms of renal cell cancer was additional evidence in support of the appellant's claim and also that although cancer is genetic; there was no history of cancer in the Veteran's family. In support of her claim, the appellant has submitted a number of medical treatise articles which discuss the incidence of secondary malignancies occurring after treatment for Hodgkin's lymphoma. A VHA opinion was obtained in July 2012. The examiner reviewed the entirety of the claims file, medical history, and relevant medical literature. Based on his review, the examiner opined that "it is less likely than not that the Veteran's renal cell carcinoma was caused by chemotherapy treatment for service-connected Hodgkin lymphoma or by Hodgkin lymphoma itself." Specifically the VHA examiner concluded that the medical literature that describes the co-existence of two cancers does not provide any evidence that one caused the other, as other factors cannot be ruled out, such as exposure to carcinogens and underlying genetic defects. Additionally, while the articles discussed the co-existence of renal cancer and non-Hodgkin lymphoma, the Veteran had Hodgkin lymphoma, which is a different disease. Similarly, the VHA examiner noted that while there is clearly a documented increased risk of second malignancy including solid tumors after treatment of Hodgkin lymphoma, the risk relates to very specific types of cancers. There was very little evidence in the literature of any increased risk of renal cancer and no evidence of increased risk of papillary renal cancel. While there are case reports showing renal cancel after treatment with chemotherapy, this was insufficient to conclude an association. The VHA examiner particularly noted that the Veteran did not suffer from the treatment for his Hodgkin lymphoma after remission; rather he had reasonably good health with no evidence of symptoms or immune suppression for the years in between his diagnoses. As noted, the Board has the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden, supra. However, the Court has held that the Board may not reject medical opinions based on its own medical judgment. See Obert, supra; Colvin, supra. In this case, the Board places greater weight of probative value on the VHA expert medical opinion and the VA examiner's opinions then the testimony of Dr. B.W. and the medical treatise articles submitted by the appellant. As noted above, Dr. B.W. indicated that his opinion was based on speculation because he did not have access to the Veteran's medical records or laboratory reports. Moreover, Dr. B.W. did not explain why the Veteran's Hodgkin's disease would have been compromised by his service-connected Hodgkin's disease when the record indicates that the Hodgkin's disease was in remission when the Veteran was diagnosed with renal cell carcinoma. With respect to the medical treatise evidence submitted by the appellant, these articles reference medical information that is general in nature and do not address the specific facts of the Veteran's case. Moreover, the VHA examiner clearly distinguished the Veteran's case of Hodgkin's lymphoma and subsequent development of renal cell carcinoma from the non-Hodgkin's cancers discussed in the articles. The VHA medical expert also noted that while the articles suggested a concurrence between Hodgkin's disease and renal cell carcinoma, there was insufficient evidence to show causation. While the Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin, supra; see also 38 C.F.R. § 3.159(a)(1). In this case, the medical treatise articles are less probative than the opinion of the VHA examiner. Specifically, as noted above, the medical treatise articles are general in nature and does not specifically related to the facts and circumstances surrounding the Veteran's particular case. Moreover, these articles were reviewed by the VHA examiner, who also reviewed the Veteran's medical history and determined that the Veteran's kidney cancer was not related to his service-connected Hodgkin's disease or the treatment therefore. The Board has also considered the appellant's statements that the Veteran's renal cell cancer is related to his service-connected Hodgkin's lymphoma. However, her opinion is accorded no greater evidentiary value than that of the private medical opinions and articles. See Jandreau, supra. Her opinion is lacking in specifics and detail and is therefore accorded little probative value. Based on the above, the Board finds the October 2008 and September 2010 VA examiner and the July 2012 VHA report to be more probative than the general medical treatise articles, the unsupported opinion from Dr. B.W. and the appellant's assertions that the Veteran's service-connected Hodgkin's disease caused or contributed to his death. While the Board is sympathetic to the appellant's contentions, in the final analysis, the preponderance of the evidence is against her claim. As such, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The appellant's claim of entitlement to service connection for the cause of the Veteran's death must be denied. ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs