Citation Nr: 1320813 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 09-07 706 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and Veteran's son ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran had active service from May 1968 to August 1974. He died in November 2007. The appellant seeks surviving spouse benefits. This case comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Jackson, Mississippi (RO). The appellant and the Veteran's son testified at a hearing before the Board in July 2010. In March 2011, the Board denied claims of entitlement to service connection for lung cancer for the purpose of accrued benefits and entitlement to service connection for the cause of the Veteran's death. Thereafter, the appellant filed an appeal with the United States Court of Appeals for Veterans Claims. In a December 2011 Joint Motion for Partial Remand, the appellant and VA agreed that VA should obtain a medical opinion as to whether the Veteran's cause of death was related to service. The Joint Motion noted that the appellant did not intend to pursue an appeal of the claim of entitlement to service connection for lung cancer for the purpose of accrued benefits and that claim should be considered abandoned. In its January 2012 Order, the Court remanded the cause of death claim and dismissed the appeal of the lung cancer claim. The appellant was advised in a May 2012 letter that the Acting Veterans Law Judge who conducted the July 2010 hearing is no longer employed by the Board. She was informed that the law requires that the Veterans Law Judge who conducts a hearing on appeal must participate in any decision made on that appeal. 38 U.S.C. § 7207(c) (West 2002); 38 C.F.R. § 20.707 (2012). She was advised that her appeal may be reassigned to another Veterans Law Judge for a decision if she waived her right to another hearing. 38 C.F.R. § 19.3(b) (2012). The appellant submitted a response to the letter in May 2012 and indicated that she did not want to appear at another Board hearing. The Board has reviewed the claims file and the Virtual VA electronic claims file. FINDINGS OF FACT 1. The Veteran died in November 2007 at the age of 58 as a result of cardiopulmonary arrest due to, or as a consequence of, esophageal lung cancer. 2. At the time of death, the Veteran was service-connected for posttraumatic stress disorder (PTSD), rated 70 percent; monomelic amotrophy of the left upper extremity, rated 40 percent; and hemorrhoids rated 0 percent. The Veteran was also in receipt of benefits for total disability based on individual unemployability due to his service-connected disabilities since April 2000. 3. The evidence of record establishes that the Veteran served in the Republic of Vietnam during the Vietnam Era and herbicide exposure is presumed. 4. The evidence of record does not show that esophageal cancer is on the list of disorders presumed service connected for herbicide exposure and that disorder is otherwise not shown by the evidence to be etiologically related to service 5. The evidence of record does not demonstrate that a disability of service origin caused or contributed to the Veteran's death. CONCLUSION OF LAW The criteria for entitlement to service connection for the cause of the Veteran's death have not been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 1310, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has a duty to notify and a duty to assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction, of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183, (2002). The notice requirements apply to all five elements of a service-connection claim, to include Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the context of a claim for dependency and indemnity compensation (DIC) benefits, the 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. 38 U.S.C.A. § 5103 (West 2002); Hupp v. Nicholson, 21 Vet. App. 342 (2007). The appellant has not alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Board finds that VA's duty to notify has been satisfied. The appellant was notified in letters dated in December 2007 and July 2008 of the criteria for establishing service connection for the cause of death, the evidence required, and her and VA's respective duties for obtaining evidence. She also was notified of how VA determines disability ratings and effective dates in the July 2008 correspondence. The July 2008 notice letter was provided after the initial unfavorable AOJ decision in February 2008. However, VA can provide additional necessary notice subsequent to the initial AOJ adjudication, followed by a readjudication of the claim, such that the essential fairness of the adjudication, is unaffected because the appellant was provided a meaningful opportunity to participate effectively in the adjudication of the claim. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The provision of adequate notice prior to a readjudication cures any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. Prickett v. Nicholson, 20 Vet. App. 370 (2006). After adequate notice letters were provided to the appellant, the claim was readjudicated in a January 2013 supplemental statement of the case. As for the duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. The service medical records have been obtained. There is no indication of any other relevant evidence in VA's possession, but not in the claims file, or of any available evidence that VA must seek to obtain. The parties in the Joint Motion agreed that in the March 2011 decision that a medical opinion was not necessary prior to adjudication of the claim. Pursuant to a Board remand issued in August 2012, the Board requested a VA medical opinion, which the Board received in January 2013. The Board finds that opinion is adequate for the adjudication of the claim. In its August 2012 remand, the Board also instructed the RO to contact the appellant and request that she provide contact information for the hospice where the Veteran was treated from September 2007 until he died in November 2007. The appellant did not respond to the RO's August 2012 letter. Therefore, the claims file does not contain the medical records of the Veteran's final treatment before his death. However, the amended death certificate clearly shows that he died from cardiopulmonary arrest due to esophageal lung cancer and there is no dispute or allegation that any of his three service-connected disabilities was a principal or contributory cause of death. Thus, the record indicates that VA made reasonable efforts to obtain any relevant treatment records. VA's duty to assist is not always a one-way street and the claimant cannot remain silent when the claimant has information or authorization necessary to obtain evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). The Board concludes that all available records and medical evidence have been obtained in order to make a decision. Therefore, no further notice or assistance is required to fulfill VA's duty to assist in the development of this claim. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Therefore, the Board finds that VA has fulfilled the duty to assist. 38 U.S.C.A. § 5103A (West 2002). Service connection may be established for the cause of a veteran's death when a service-connected disability was either the principal or a contributory cause of death. 38 C.F.R. §§ 3.303, 3.304, 3.312(a) (2012); 38 U.S.C.A. §§ 1110, 1112, 1310 (West 2002). A service-connected disability is the principal cause of death when that disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b) (2012). A contributory cause of death must be causally connected to the death and must have contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1) (2012); Harvey v. Brown, 6 Vet. App. 390 (1994). Accordingly, service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. The record show that at the time of his death, the Veteran was service-connected for posttraumatic stress disorder (PTSD), a left upper extremity disorder, and hemorrhoids. Accordingly, the Veteran's death is not shown to have been caused by an already service-connected disability. Nevertheless, the appellant may establish service connection for the cause of the Veteran's death when all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. Combee v. Brown, 34 F. 3d. 1039 (Fed. Cir. 1994). When any veteran dies after December 31, 1956, from a service-connected or compensable disability, VA will pay dependency and indemnity compensation (DIC) to the veteran's surviving spouse, children, and parents. 38 U.S.C.A. § 1310 (West 2002). In a claim where service connection was not established for the fatal disability prior to the death of the veteran, the initial inquiry is to determine whether the fatal disorder had been incurred in or aggravated by service. The Board must determine whether the fatal disorder should have been service-connected. 38 C.F.R. § 3.312 (2012). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). The law also provides that service connection may 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) (2012). Generally, to establish service connection, there must be (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may be granted on a presumptive basis for certain chronic diseases, including malignant tumors, if they are shown to be manifest to a degree of 10 percent or more within one year following the veteran's separation from active military service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). For purposes of establishing service connection for a disability resulting from exposure to herbicides, a veteran who, during active service, served in the Republic of Vietnam between January 1962 and May 1975, shall be presumed to have been exposed during that service to herbicides. 38 U.S.C.A. § 1116(f) (West 2002). When a veteran was exposed to herbicides during active service, the following diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are satisfied: Chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes (also known as Type II diabetes or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including a myocardial infarction and coronary artery disease), all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), . 38 C.F.R. § 3.309(e) (2012). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more any time after service, except that chloracne, porphyria cutanea tarda, and peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.307(a)(6)(ii) (2012). An appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination medical in nature and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the evidence in favor of the claim is in relative balance with the weight of the evidence against the claim, and the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, that reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2012). The appellant seeks service connection for the cause of the Veteran's death. The appellant has indicated that the Veteran, a Vietnam War veteran and recipient of the Combat Infantryman Badge (CIB), suffered from lung cancer due to exposure to herbicides in service and that the lung cancer spread from the Veteran's lung to the esophagus and ultimately led to the cause of the Veteran's death. She essentially contends in numerous written submissions that service medical records and post-service VA records show that the Veteran developed cancer as a result of exposure to herbicides during his service in Vietnam. She appears to contend that skin tumors removed from 1995 and after were cancerous and that esophageal cancer and lung cancer were related to those cancers and they were all caused by exposure to herbicides. At the time of his death, the Veteran was service-connected for PTSD, rated 70 percent; monomelic amotrophy of the left upper extremity rated 40 percent; and hemorrhoids rated 0 percent. The Veteran was also in receipt of benefits for individual unemployability based on his service-connected disabilities since April 2000. He had also filed a claim for service connection for lung cancer, but that claim was pending at the time of his death in November 2007. The appellant then sought service connection for lung cancer for the purpose of accrued benefits, which the Board denied in its March 2011 decision. The appellant abandoned that claim during her appeal of the Board denial. Service personnel records show that the Veteran served in Vietnam from November 1968 to April 1969. The service medical records do not show any treatment or diagnosis for esophageal or lung cancer. After service, a VA treatment record dated in August 1984 indicated masses on the right elbow and left knee similar to a present left elbow mass. A January 1985 Agent Orange registry document signed by a physician contains no references or indications of esophageal or lung cancer. Information in the claims file indicates that the Veteran successfully applied for disability payments from the Agent Orange Veteran Payment Program, apparently part of a settlement arising out of litigation in a federal court in New York. The March 1992 award letter stated that the Veteran became totally disabled in January 1984. VA treatment records in 1995 show the removal of giant cell tumors from the third digit of the right hand. A May 1997 VA medical record noted the Veteran's complaint of a six-month history of wart-appearing lesions on his right index finger and his left thumb. An October 1997 VA medical record indicated that a giant cell tumor of the tendon sheath was removed from the Veteran's right index finger. A May 2000 VA medical record noted knots on the Veteran's right hand and left forearm with etiology unknown. A June 2000 VA examination noted that the Veteran planned surgery to remove knots from his right hand and left forearm. On examination, firm nodules were noted about the fingers and hands, but there was no reference to past malignant cancers or any current concern expressed about skin cancer. A July 2000 VA medical record shows that the Veteran was scheduled for surgery to remove a lesion from his right hand. The Veteran was admitted for treatment for pericarditis in June 2007 at which time an esophageal mass was found. The evidence shows that the Veteran presented for treatment at VA in June 2007 with a 40-pound weight loss over the prior ten months, complaints of throat pain for the prior two to three weeks, and a recent onset of dysphagia/odynophagia. A CT scan in that month showed an esophageal mass with lymph nodes less than 1 centimeter in size. It was indicated at that time that metastases was a likely possibility but needed further confirmation. A July 2007 positron emission tomography (PET)/computed tomography (CT) scan revealed esophageal malignancy with mediastinal lymph node metastasis, 4 centimeter hypermetabolic mass or infiltrate located in the right lower lobe, and small right-sided pleural effusion with mild metabolic activity. An esophogram in August 2007 confirmed a fistulous tract into the right lung cavity. In August 2007, the Veteran was assessed with stage IV esophageal cancer with a fistula to the right lower lobe of the Veteran's lung. The records show that the Veteran was treated with a palliative stent. The records indicate that the tumor board determined that the best course of treatment for the Veteran's esophageal mass was radiation followed by palliative chemotherapy. An entry dated in September 2007 indicates that the Veteran desired to stop radiation although he was willing to take chemotherapy. The Veteran was advised that chemotherapy was not for a cure and was a form of palliation and he was given the option of going on hospice care for comfort measures. The Veteran thereafter decided to cease all treatment and hospice care was ordered. The Veteran was transferred for hospice care in September 2007 prior to his death in November 2007. The Veteran's original death certificate shows that the immediate cause of the Veteran's death was cardiopulmonary arrest. An amended death certificate indicates that the immediate cause of the Veteran's death was cardiopulmonary arrest due to or as a consequence of esophageal lung cancer. In July 2010, the appellant testified that the amended death certificate arose when a new coroner took office and reviewed evidence. She also said that her husband was treated at VA for lung cancer. She contended that no doctor had ever provided a definite origin of the cancer, so the lung cancer should have been service-connected. She also testified that a doctor told her that her husband had cancer for two to three years and that while her husband was going to medical appointments no one ever told him that he had cancer. She also said that her husband had been dealing with cancer since 1995, that cancerous growths were removed from his hand and they were malignant but he was told they were benign, that he had been dealing with Agent Orange all his life after his discharge, and that during his last year medical records show that he was going to have another giant tumor removed from his leg. Her son testified that when the Veteran was taken to the hospital in June 2007 he was having difficulty breathing. As a result of the Board's August 2012 remand, a medical opinion for this case was prepared by a VA physician. In a January 2013 report, a VA physician noted that the Veteran's discharge examination of August 1974 was silent for cancer; that VA treatment records dated in 1995, 1997, February 2005, and March 2007 showed normal chest X-rays; and that there was no medical evidence for the lung, rather than the esophagus, being the primary cancer in a review of medical records dated in the summer of 2007. The January 2013 VA reviewer opined that esophageal cancer was not related to service, including herbicide exposure; that esophageal cancer was the primary site of cancer; that esophageal cancer led to the Veteran's death; and that there was no evidence in the case that any of the Veteran's service-connected disabilities contributed to its development or to cardiopulmonary arrest. The VA reviewer noted that there was no evidence of a primary cancer in the lungs, bronchus, larynx, or trachea. The physician stated that the Veteran's chest X-rays between 1995 and 2007 were negative for a pulmonary mass and that a June 2007 CT scan upon initial diagnosis of a large esophageal mass showed right lower lobe passive atelectasis from adjacent adenopathy but was negative for pulmonary mass. The July 2007 PET scan showed an abnormality in the right lower lobe but could not definitively differentiate between mass or infiltrate. An August CT scan showed esophageal malignancy with fistula formation to the lower lobe with resultant cavitary pneumonia. The physician further noted that oncology specialists noted in the record that the diagnosis was cancer of the esophagus as the primary cancer with an esophagus to the right lower lobe fistula/abscess as a complication. Based on the foregoing, the Board finds that the preponderance of the evidence weighs against the claim for service connection for the cause of the Veteran's death and the appeal must be denied. Following review of the complete record, the Board finds that the weight of the competent evidence of record does not show that service connection is warranted on the theory that the Veteran's death was a result of an in-service disease or occurrence. In reaching this decision, the Board acknowledges the appellant's assertion that the Veteran's esophageal and lung cancers were due to in-service exposure to herbicides. The Board notes that herbicide exposure is conceded based on the Veteran's Vietnam service. Thus, exposure to herbicides during service is presumed. Moreover, the Board finds that while it has been conceded that the Veteran was exposed to herbicides during his service in Vietnam, he was not diagnosed with a type of cancer that has been shown to have a positive association with exposure to herbicides. The Veteran's death is primarily attributable to esophageal cancer. That form of cancer has not been classified as a cancer for which presumptive service connection is warranted based upon exposure to herbicide agents. 38 C.F.R. §§ 3.307(a)(6)(iii); 3.309(e) (2012). Esophageal cancer is not included in the diseases identified in 38 C.F.R. § 3.309(e) and therefore, exposure to an herbicidal agent is not presumed to have caused the disability. Thus, service connection cannot be granted for esophageal cancer on that presumptive basis. Furthermore, no malignant tumor was shown within one year of the Veteran's separation from service, so presumptive service connection cannot be granted on that basis. Lung cancer, but not esophageal cancer, is listed as one of the diseases presumed to be due to exposure to herbicides. 38 C.F.R. § 3.309(e) (2012). However, a presumptive cancer, such as lung cancer, which develops as a result of a metastasizing non-presumptive cancer may not be presumed service-connected. 38 U.S.C.A. § 1116(a) (West 2002); 38 C.F.R. § 3.307(a) (2012); VAOPGCPREC 18-97 (1997), 62 Fed. Reg. 37954 (1997); Darby v. Brown, 10 Vet. App. 243 (1997) (presumption of service connection for lung cancer rebutted by medical evidence showing that stomach was primary site); Ramey v. Brown, 9 Vet. App. 40 (1996) (presumption of service connection for liver cancer did not apply because carcinoma of the liver was result of metastasis from colon cancer, rather than from primary liver cancer). When a Veteran is found not to be entitled to a regulatory presumption of service connection for a disability, the claim must be reviewed to determine whether service connection can be established on another basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Therefore, the Board will adjudicate the claim on a theory of direct entitlement to service connection for esophageal cancer. In this case, the service medical reports, to include the reports from the August 1974 separation examination, do not show any evidence of esophageal or lung cancer. The post-service evidence also does not contain any medical finding or opinion linking the Veteran's esophageal cancer to service, or to exposure to herbicides during service, which weighs heavily against the claim. Hickson v. West, 12 Vet. App. 247 (1999). Also weighing against the claim is the fact the first evidence of the Veteran's esophageal cancer is dated in 2007, more than 30 years after separation from service. The Board notes that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Accordingly, service connection for esophageal cancer or esophageal lung cancer is not warranted based on a theory of in-service disease or occurrence. The appellant has not provided any persuasive medical evidence to support her assertion that the Veteran had esophageal cancer that was due to exposure to herbicides in service. The Veteran's claims file was reviewed by a VA physician, for the purposes of determining whether the Veteran's death was due to service, including exposure to herbicides during service. The VA expert opined that there was no persuasive medical evidence in the record that esophageal cancer either manifested during the Veteran's service or developed as a result of his service and that there was no evidence that any of the Veteran's service-connected disabilities contributed to the development of esophageal cancer or to the Veteran's cardiopulmonary arrest. The VA medical expert's opinions are considered highly probative in this case as they are definitive, prepared by a physician, based upon a complete review of the Veteran's entire claims file, and supported by detailed rationales. Accordingly, those opinions are found to carry significant probative weight. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444 (2000). The Board concludes that the VA reviewer's findings constitute the most probative and persuasive evidence on the question of whether the Veteran's death was due to in-service exposure to herbicides. Hayes v. Brown, 5 Vet. App. 60 (1993) (responsibility of Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. The credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). There is no competent evidence linking any esophageal cancer diagnosed in the last months of the Veteran's life to any event or incident of service. Competent medical evidence means evidence 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) (2012). Competent lay evidence is defined as any evidence not requiring that the proponent have specialized education training or experience but is provided by a person who has the knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2) (2012). No post-service record or medical opinion suggests that the etiology of esophageal cancer was a disease or injury in service, including exposure to herbicides. The January 2013 VA medical expert noted that the record contained no evidence of cancer in service. In this case, the only evidence linking esophageal cancer to service is the appellant's statements. The appellant has not been shown to have the education or training to render her competent to provide an opinion as to the etiology of a medical condition which is not easily observed. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the appellant is not competent to provide an opinion that the Veteran's death was etiologically related to service or to exposure to herbicides in service. While the appellant is competent to report the Veteran's symptoms that she observed as they came to her through her senses, esophageal cancer is not the type of disorder about which a lay person can provide competent evidence on questions of etiology or diagnosis. The Board has determined that the VA physician's opinion is more probative and included a sufficient rationale, which was based on medical training and a review of the claims file. Thus, the Board attaches greater probative weight to the clinical findings of the VA reviewer than to the lay statements submitted by the appellant. Furthermore, while the appellant may believe the Veteran was exposed to herbicides in service and that exposure led to a variety of cancers in the Veteran's lifetime, including his diagnosis of esophageal cancer, the record does not corroborate that assertion. Even though the Veteran's exposure to herbicides is presumed, the appellant's assertion is not credible. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Caluza v. Brown, 7 Vet. App. 498 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). The Board notes that the appellant has not asserted that the Veteran's death was due to a service-connected disability, and instead attributed his death to in-service exposure to herbicides. Direct or presumptive service connection is not warranted for esophageal cancer and the Veteran's three service-connected disabilities are not mentioned on his amended death certificate, or otherwise shown by any competent evidence to have caused or contributed to his death. In addition, the January 2013 VA medical reviewer specifically found that none of the Veteran's service-connected disabilities contributed to the development of esophageal lung cancer or to cardiopulmonary arrest. Therefore, there is no disability of service origin that can be considered as either the principal or contributory cause of death. Therefore, service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. § 1310(b) (West 2002); 38 C.F.R. § 3.312 (2012). While the appellant has provided numerous copies of post-service VA medical records, she did not provide VA with copies of her husband's hospice records. In the absence of competent evidence providing a link between esophageal cancer and the Veteran's service, to find the Veteran's esophageal cancer was related to his active service would require speculation. The law has recognized that service connection may not be based on resort to speculation or remote possibility. 38 C.F.R. § 3.102 (2012) (2012); Stegman v. Derwinski, 3 Vet. App. 228 (1992); Obert v. Brown, 5 Vet. App. 30 (1993). Although the Board is sympathetic to the appellant's assertions, understands her position, and does not want to minimize the service the Veteran provided, the claim for service connection for the Veteran's cause of death must be denied because the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for the cause of the Veteran's death is denied. ____________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs