Citation Nr: 1322889 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 09-18 846A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for left breast segmental resection/lumpectomy, with left axillary lymph node extraction, claimed as residuals of left breast cancer due to petroleum exposure. 2. Entitlement to service connection for hysterectomy, claimed as due to petroleum exposure and/or as secondary to left breast cancer. 3. Entitlement to service connection for left brachial nerve damage, claimed as secondary to left breast segmental resection/lumpectomy. 4. Entitlement to service connection for gallbladder extraction, claimed as due to petroleum exposure. REPRESENTATION Veteran represented by: New York State Division of Veterans' Affairs WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1985 to March 1986 and from October 1987 to May 1988. She also completed subsequent reserve service, including multiple periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA), through July 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. Although the case currently remains under the jurisdiction of the RO in New York, the Board observes that a transfer of jurisdiction may be in order since the Veteran moved to Maine after her appeal was certified to the Board. In pertinent part, the August 2007 rating decision denied service connection for residuals of the Veteran's breast cancer, hysterectomy, and gallbladder extraction. The Veteran timely disagreed with the denials. The RO subsequently issued a May 2009 statement of the case (SOC). The Veteran responded later in May 2009 with her substantive appeal (via a VA Form 9). Although the Veteran also initiated an appeal as to a denial of service connection for a right ankle disorder, the agency of original jurisdiction (AOJ) subsequently granted service connection for that disability in a May 2009 rating decision. As such is a full grant of the benefit sought on appeal, that issue is no longer before the Board for appellate review. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). [Parenthetically, the Board observes that the Veteran has since filed a claim of entitlement to an increased rating for her right ankle, as well as additional claims for service connection, that, as reflected by the claims file, are currently being developed by the AOJ.] In regard to the characterization of the claims, the Board notes that the RO, in the August 2007 rating decision, adjudicated service connection for left breast segmental resection/lumpectomy, left axillary lymph node extraction, and brachial nerve damage as separate claims. However, in the May 2009 SOC, those disorders were addressed as a single claim and they were, subsequently, certified to the Board as a single claim. The Board notes that certification is used for administrative purposes and does not serve to either confer or deprive the Board of jurisdiction over an issue. 38 C.F.R. § 19.35 (2012). As the Board's review of the case file indicates that the left breast segmental resection/lumpectomy, with the left axillary lymph node extraction, was the required treatment for the Veteran's breast cancer, those two disorders have been paired together, as a single claim, as reflected on the title page. However, the evidence does not indicate whether left brachial nerve damage was a required treatment or was an additional disability incurred by the Veteran as the result of her treatment at a private hospital. As such, that disability is addressed above as a separate claim and will be remanded, below, for additional development. The Veteran testified before a Decision Review Officer (DRO) in March 2009 at the RO. In June 2012, the Veteran testified via video-conference before the undersigned Veterans Law Judge. Transcripts of both hearings have been associated with the claims file. At the time of the Veteran's Board hearing, the undersigned Veterans Law Judge observed that additional evidence had been added to the claims file since the issuance of the May 2009 SOC. On the record at the hearing, the Veteran waived AOJ consideration of this evidence. 38 C.F.R. § 20.1304(c). Therefore, the Board may properly consider the subsequently received evidence. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal. A review of the virtual file reveals additional VA treatment records that were added to the record in January 2012 and September 2012 and were not considered by the AOJ in connection with her claims currently before the Board; however, as indicated in the preceding paragraph, the Veteran waived AOJ consideration of all such evidence received since the May 2009 SOC. Therefore, the Board may properly consider such records. The issues of service connection for left brachial nerve damage and gallbladder extraction are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Resolving all doubt in her favor, the Veteran's left breast cancer is etiologically related to her military service, to include petroleum exposure. 2. The Veteran's hysterectomy is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include petroleum exposure, and was not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for left breast segmental resection/ lumpectomy, with left axillary lymph node extraction, are met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). 2. Hysterectomy was not incurred in or aggravated by the Veteran's active duty military service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and 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); 38 C.F.R. § 3.159(b) (1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. As the Board's decision to grant service connection for left breast segmental resection/lumpectomy, with left axillary lymph node extraction, herein constitutes a complete grant of those benefits sought on appeal, no further action is required to comply with the VCAA and the implementing regulations in specific regard to that claim. Relevant to the Veteran's claim for service connection for a hysterectomy, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a January 2007 letter, sent prior to the initial unfavorable rating decision, advised the Veteran of the evidence and information necessary to substantiate a claim for service connection, as well as her and VA's responsibilities in obtaining such evidence and information. This letter also informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Although the Veteran has not been specifically advised of the criteria for establishing service connection on a secondary basis, her hearing testimony and written statements establish that she understands what evidence is required to substantiate a service connection claim on a secondary basis. Gallegos v. Peake, 22 Vet. App. 329, 338-39 (2008). In further regard to the duty to notify, and in specific regard to the Veteran's June 2012 Board hearing, Court has held that that provisions of 38 C.F.R. § 3.103(c) (2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: to explain fully the issues, and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing in this case, the undersigned Veterans Law Judge discussed the evidence necessary to substantiate a claim for service connection. The Veterans Law Judge specifically inquired as to basis of the Veteran's contentions as to why service connection was warranted for her hysterectomy and indicated that medical evidence supportive of those contentions would assist her in substantiating her claim. Accordingly, the Bryant duties were met, and the hearing is legally sufficient. In regard to the DRO hearing, the Board also finds that appropriate colloquies were conducted during that proceeding in accordance with Stuckey v. West, 13 Vet. App. 163 (1999) and Constantino v. West, 12 Vet. App. 517 (1999). Relevant to the duty to assist, the Veteran's service treatment and personnel records, as well as VA and private treatment records, have been obtained and considered along with research/treatise evidence submitted by the Veteran. Although the claims file reflects a copy of a November 1985 enlistment examination submitted by the Veteran, it does not reflect other records of examination or treatment from the Veteran's first period of active duty (in the Navy, from November 1985 to March 1986) or that the RO made inquiry to obtain such records. In this regard, the Board notes she submitted the copy of the 1985 examination in regard to her claim for an ankle disability. The Board observes that the duty to assist by obtaining records in the custody of a Federal department extends only to "relevant records." 38 C.F.R. § 3.159(c)(2). Here, the Veteran has not contended, and the file does not indicate, that any records from her naval service are pertinent to her claims. Specifically, she has contended that the claimed disabilities result from petroleum exposure during her second term of active duty service, in the Army and has stated that she was not exposed to any such chemicals during her first period of service. Further, the Veteran has not contended, and the evidence does not suggest, that any claimed disability began, or was aggravated, during her first period of service. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (the Board only must address theories of entitlement raised by the Veteran or by the evidence of record). Consequently, the Board concludes that the Veteran has not been prejudiced by the lack of these records. Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran has not identified any additional, outstanding records that have not been requested or obtained. Although the Veteran has informed VA that she is in receipt of disability benefits through the Social Security Administration (SSA), she has indicated her claim for SSA benefits was based only on disability of the back and there is no indication that the SSA records are pertinent to her claims for breast cancer residuals or hysterectomy. See Golz v. Shinseki, 590 F. 3d 1317 (Fed. Cir. 2010) (holding that "there must be specific reason to believe [SSA] records may give rise to pertinent information to conclude that they are relevant"). Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Additionally, the Veteran was afforded a VA examination in July 2007, a review opinion was obtained in April 2009 (with May 2009 clarification), and an opinion was obtained from a Veterans Health Administration (VHA) medical expert in January 2013. The July 2007 examiner did not provide any etiological opinions and the April/May 2009 opinion reflects that the examiner could not render an opinion without resort to speculation. However, the January 2013 expert offered etiological opinions that the Board finds are adequate to decide the issue. The opinion is based, in part, on the July 2007 physical examination of the Veteran and it also reflects review of the pertinent evidence of record and includes in-depth analysis of the treatise evidence submitted by the Veteran. The ultimate opinions proffered by the expert considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided complete rationales, relying on, and citing to, the records reviewed. Moreover, the expert offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issues decided herein has been met. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis The Veteran contends that she incurred left breast cancer and hysterectomy as the result of her in-service exposure to petroleum. She has also claims that her hysterectomy was the result of treatment required for her left breast cancer. Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. Id. ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserves. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full-time duty performed by a member of the Reserves or the National Guard of any State. 38 C.F.R. § 3.6(d). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as malignant tumors, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While the Veteran's left breast cancer may be considered a malignant tumor, her hysterectomy is not a disease recognized as chronic under 38 C.F.R. § 3.309(a) and the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable to such claim. Service connection also may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended effective October 10, 2006. As the Veteran filed her claim in November 2006, the amended regulations apply. Such provide that VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b) (2012). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service records reflect that she served as a petroleum supply specialist during her active duty service. She has reported serving as a clerk and fuel supplier during her reserve service. A February 1987 service enlistment examination reflects that the Veteran was examined as normal and qualified for enlistment, although an HCG test initially indicated pregnancy. She completed a concurrent self report of medical history on which she indicated that she had experienced change in her menstrual patterns and had been treated for female disorder. She specified later in the self report that she had a history of irregular menses and had undergone a tubal ligation prior to any period of service. During a January 1996 examination performed as part of her reserve service, a physician noted her prior tubal ligation. However, the Veteran noted on a concurrent self report of medical history that she had not been treated for any female disorder and had not experienced change in menstrual pattern. No reproductive system disorders were noted. Subsequently, in July 1998, the Veteran sought private medical treatment for left-sided substernal chest pain. After a negative cardiac work-up, she was noted to have a left breast mass and underwent biopsy that revealed cancer. In September 1998, she underwent left segmental breast surgery with lymph node dissection. As one node was positive for cancer, she was started on a course of chemotherapy from October to December 1998. In December 1998, the Veteran experienced uterine bleeding that was attributed to uterine fibroids and cyst. She reported a history of pelvic pain with extended monthly periods with increased clotting and menorrhagia. She specifically reported periods in October and November 1998 that lasted 12 days. The Veteran underwent hysterectomy on January 29, 1999. Biopsy of the endometrial cutterings revealed cervicitis and cysts, but no malignancy. Further cancer treatment was subsequently provided in regard to her left breast cancer. These treatments included use of Tamoxifen beginning in February 1999 as well as radiation therapy. All treatments were completed in April 1999 and private physician notes dating from August 2000 show no recurrence. The Veteran was afforded a VA examination in July 2007. Pelvic examination was normal except for note of the hysterectomy. Left breast examination was normal except for the surgical residuals of the Veteran's resection and lumpectomy. The examiner diagnosed the Veteran with left breast cancer, status post lumpectomy and lymph node dissection with chemo-, radiation, and hormonal therapy. The examiner also stated that the Veteran was "status post total hysterectomy due to vaginal bleeding while taking Tamoxifen." In April 2008, the Veteran submitted multiple studies to VA that correlated increased risk of breast cancer to work around heavy concentrations of petroleum. The following submitted studies all report on such a correlation: * Occupational Cancer, Journal of Environmental Health, Vol. 44, No. 4, pp. 176-79 (1982). * Risk of Breast Cancer Among Enlisted Women Occupationally Exposed to Volatile Organic Compounds, American Journal of Industrial Medicine, Vol. 48, No. 3, pp. 157-67 (2005). * Elevated Risk for Male Breast Cancer After Occupational Exposure to Gasoline and Vehicular Combustion Products, American Journal of Industrial Medicine, Vol. 37, No. 4, pp. 349-52 (2000). * Diesel Exhaust Influences Carcinogenic PAH-induced Genotoxicity and Gene Expression in Human Breast Epithelial Cells, Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis, Vol. 525, No. 1-2, pp. 72-82 (2007). In March 2009, the Veteran testified before a DRO at the RO. She reported being exposed to large quantities of petroleum on a very regular basis beginning during her active duty Army service from October 1987 to May 1988 and continuing through her reserve service. She stated that she believed that exposure was responsible for her left breast cancer. Her authorized representative characterized hysterectomy as a "problem related to the cancer and the drugs that she needed to take." Subsequent to that hearing, the Veteran resubmitted copies of the studies correlating petroleum exposure to breast cancer. VA provided the Veteran's claims file to another VA examiner in April 2009 for an opinion regarding the submitted research evidence. Although acknowledging that the Veteran's military duties may have placed her at greater risk for the development of breast cancer, the examiner opined that such correlation could not be stated with any certainty as the Veteran only completed seven months of active duty with near daily exposure to petroleum. In May 2009, the RO sought clarification from the examiner, but the examiner stated he could "not resolve this issue without resort to mere speculation." The Veteran wrote to VA in June 2009 and contended that the length of her exposure to petroleum was longer than seven months as she continued to work with that substance during her reserve service. She also observed that the latency period between her initial exposure and her breast cancer was approximately 10 years, and the research she submitted stated that latency periods can range from 10 to 40 years. She also submitted another study - Cancer Incidence in the U.S. Military Population: Comparison with Rates from the SEER Program, Cancer Epidemiology Biomarkers & Prevention, Vol. 18, p. 1740 (2009) - which reported a higher incidence of breast cancer among active duty populations in general. In June 2012, the Veteran testified before the Board. She reiterated her contention that she experienced left breast cancer as a result of her active duty and reserve exposures to petroleum. She again discussed the research she had submitted and expressed a belief in the existence of a causal relationship between petroleum and breast cancer. The Veteran and her authorized representative both contended that she experienced uterine bleeding, requiring hysterectomy, as the result of the use of Tamoxifen in her breast cancer treatment regimen. The Board sought a VA expert medical opinion in regard to the Veteran's contentions as to the etiology of left breast cancer and hysterectomy. In January 2013, the expert, a medical oncologist with more than three decades of experience, responded to the Board's inquiry. The expert summarized the Veteran's service, her contentions, and her medical history. He then explained the scientific concepts that are used to establish the causality of cancer from any environmental exposure and wrote an overview of scientific evidence linking breast cancer to petroleum exposure, which included assessment of the research evidence submitted by the Veteran. He observed that some research supported an almost 30 percent increase in breast cancer incidence in women who had worked with volatile organic chemicals for at least one year. Although he noted that exposure to petroleum could result in increased risk of breast cancer, he stated that he could not provide a precise probability in regard to the Veteran because her exposure was of "seven month's duration." In regard to the Veteran's hysterectomy, the expert stated that it was not at least as likely as not related to her military service, to include her petroleum exposure. The expert noted that biopsy of her endometrium did not reveal any cancer and was not hyperproliferative, which, he explained, could result from chemical exposure. He also opined that hysterectomy was not at least as likely as not caused or aggravated by breast cancer or Tamoxifen. He explained that the endometrium did not show effects of chronic estrogen stimulation and that, since Tamoxifen was administered after the hysterectomy was performed, Tamoxifen could not have caused the bleeding that required hysterectomy. A. Left breast segmental resection/lumpectomy, with left axillary lymph node extraction As an initial matter, the Board finds that the Veteran is competent to describe the nature and extent of her in-service experiences, to include her exposure to petroleum. See 38 C.F.R. § 3.159(a) (2); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). She has testified that, beginning in October 1987, she had daily exposure to petroleum via skin contact and inhalation of fumes. She reported that daily exposure ceased when she was discharged from active duty in May 1988, but she continued to be exposed to petroleum during her subsequent reserve service that spanned more than 10 years. The Board notes that active duty points summaries from each of her years in the reserves reflects that she actively served an approximate 130 days of reserve service. Her reported exposures are consistent with the circumstances of her service as a petroleum supply specialist. Additionally, medical evidence associated with the claims file plainly reflects that she was diagnosed with breast cancer in 1998 and that medical researchers have correlated petroleum exposure to breast cancer incidence. While the 2007 VA examiner did not provide an etiological opinion and the VA examiner who reviewed the Veteran's file in 2009 stated that he was unable, without resort to speculation, to determine whether a relationship existed between the Veteran's left breast cancer and her exposure to petroleum in service, the January 2013 oncology specialist noted that just one year of exposure to petroleum would increase breast cancer risk by 30 percent. Although the specialist stated that he could not provide a precise probability of risk in specific regard to the Veteran because she served only seven months, the Board notes that, if her approximate 130 days of active reserve service are counted, her exposure duration approximates one year. Moreover, she has submitted multiple items of treatise evidence that support the existence of a causal relationship between petroleum exposure and breast cancer. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993); also see Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). The Board finds the expert's opinion, as well as the treatise evidence submitted by the Veteran, competent and highly probative. As the Veteran's contentions about her in-service petroleum exposure is credible and supported by the record, and the existence of a causal relationship between breast cancer and such exposure is supported by the most probative medical evidence of record, the Board will resolve all doubt in her favor. Therefore, service connection for left breast segmental resection/lumpectomy, with left axillary lymph node extraction, is warranted. B. Hysterectomy As an initial matter, the Board notes that the Veteran's hysterectomy was performed prior to her discharge from the reserves. However, there is no evidence that the hysterectomy, or the bleeding that required hysterectomy, occurred on a specific date while she was performing any type of reserve service. In fact, there is no evidence that either occurred in the line of duty. Neither the Veteran nor her representative has contended otherwise and, moreover, the bleeding and the hysterectomy took place after the Veteran had begun treatment for her left breast cancer, which required curtailment of her duties. The Veteran also has not contended that hysterectomy, or the condition - uterine bleeding - that necessitated hysterectomy was incurred during, or aggravated by, any active duty service. The Board also finds no such evidence in the record - although a February 1987 self report of medical history reflects that the Veteran reported a change in menstrual patterns and a history of irregular menses, such report does not indicate excessive bleeding, let alone excessive bleeding due to fibroids/cyst as occurred immediately prior to hysterectomy. Such report also does not alter the fact that the Veteran was considered in sound condition when examined. See 38 C.F.R. § 3.304(b), (b)(1) (Only such conditions as are recorded in examination reports are considered as noted; history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions). Further, the Veteran's hysterectomy occurred more than 11 years after her discharge from active duty and she has not asserted any continuity of symptoms from that time; a 1996 examination and self report actually reflect no such symptoms as well as her denial of any menstrual irregularities. The 11 year post-service period that is negative for complaints or treatment of such symptoms is evidence that there has not been a continuity of symptomatology. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the Veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that it was proper to consider the Veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition now raised). As such, there is no basis for service connection for hysterectomy on a direct basis. 38 C.F.R. §§ 3.6(a), 3.303(a). The Board turns its attention to the Veteran's contention that service connection for hysterectomy is warranted on a secondary basis to her left breast cancer. The Veteran contends on her own behalf that her hysterectomy occurred as the result of treatment provided for her left breast cancer, specifically use of Tamoxifen. However, she has not indicated that she possesses any medical training or expertise and a layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). Lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). In the instant case, the cause of uterine bleeding involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Moreover, the record reflects that the physician-suspected reasons for her bleeding could not be confirmed without biopsy of excised tissue. As such, the Veteran's own opinion is non-probative evidence. See Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Furthermore, the Board finds the Veteran's statements that she incurred excessive bleeding during and after taking Tamoxifen not credible as they are inconsistent with the other evidence of record. Specifically, the record plainly reflects that the hysterectomy was performed on January 29, 1999 and use of Tamoxifen was not initiated until February 9, 1999. Although the July 2007 VA examiner also diagnosed the Veteran with "status post total hysterectomy due to vaginal bleeding while taking Tamoxifen," that statement speaks to timing, rather than etiology, and, as shown above, that timing is not correct. The Court has held that the Board may reject a medical opinion that is based on facts provided by the Veteran that have been found to be inaccurate or because other facts present in the record contradict the facts provided by the Veteran that formed the basis for the opinion. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). The only competent medical (italics added for emphasis) evidence of record discussing the possible etiology of the Veteran's hysterectomy is the opinion of the January 2013 expert. As noted above, that expert opined that hysterectomy was not at least as likely as not related to her military service, to include her petroleum exposure. The expert explained that the biopsy of the excised tissue revealed no evidence of any malignancy or other change that could be attributed to in-service chemical exposure or estrogen stimulation. He also noted that there was "no likelihood that the hysterectomy was caused or aggravated as a result of her left breast segmental resection/lumpectomy or from Tamoxifen," which he observed she did not use until after the hysterectomy. As the expert offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two, the Board accords great probative weight to his opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). As the most probative evidence of record reflects that the Veteran did not experience hysterectomy as the result of any disease, injury, or incident during service, to include secondary to left breast cancer and treatment, the Board finds that service connection is not warranted for a low back disorder. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hysterectomy. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for left breast segmental resection/lumpectomy, with left axillary lymph node extraction, is granted. Service connection for hysterectomy is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims for brachial nerve damage and gallbladder extraction so that she is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In the instant case, the Veteran has claimed to experience brachial nerve damage as part of her (now) service-connected breast cancer residuals. She further alleges to have experienced gall bladder extraction as the result of her in-service exposure to petroleum. Although she was afforded a VA examination in July 2007 and an expert medical opinion was associated with the claims file in January 2013, the record does not reflect any actual opinions as to the etiology of either of these disabilities. Specifically, the 2007 VA examiner did not provide opinions as to etiology. Although the examiner did refer to brachial nerve damage as due to injury during left breast surgery, the examiner did not specify whether or not that injury was an expected side-effect of the surgery, or was caused or aggravated by the breast cancer itself. The January 2013 expert did not specifically address the etiology of brachial nerve damage and stated that the question of whether or not gall bladder extraction was related to military service was outside of his expertise. As such, additional medical opinions are required. Therefore, a remand is necessary in order to obtain addendum opinions addressing such matters. Additionally, the Veteran has not been provided with proper VCAA notice regarding the secondary aspect of her claim of entitlement to service connection for brachial nerve damage. The AOJ should provide her with such notice on remand. While this case is on remand, updated VA treatment records should be obtained. Specifically, the file reflects that that the Veteran receives ongoing care from VA Medical Centers in the VA Health Care Upstate New York system. The claims file reflects that VA treatment records were last uploaded to the Veteran's virtual file in September 2012 so subsequent treatment records should be obtained and incorporated into the claims file before appellate review proceeds. Likewise, the Veteran should be given an opportunity to identify any private treatment records referable to her claimed disorders. Thereafter, the AOJ should obtain and associate any such available records with the claims file before appellate review proceeds. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with proper VCAA notice regarding the evidence and information necessary to substantiate her claim of entitlement to service connection for brachial nerve damage as secondary to her now service-connected left breast cancer residuals (left breast segmental resection/lumpectomy, with left axillary lymph node extraction). 2. Obtain all available VA treatment records dated in and after September 2012. NOTE that the Veteran has been treated at facilities in the VA Health Care Upstate New York system. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Provide the Veteran with an opportunity to submit any additional private medical evidence that is not of record. Send her the necessary authorizations for the release of any private treatment records not currently on file - specifically inquire if her private personal physician may have any records pertinent to the claims remaining on appeal. Make at least two (2) attempts to obtain records from any sources identified by the Veteran. If records from any such sources are unavailable, inform the Veteran and afford her an opportunity to submit any copies in her possession. 4. After all outstanding records have been associated with the claims file, the Veteran's claims file should be provided to an appropriate VA examiner to determine the current nature and etiology of any current left brachial nerve damage. The full claims file, to include a copy of this Remand, must be made available to, and be reviewed by, the examiner. Any indicated evaluations, studies, and tests should be conducted, to include an examination if deemed necessary by the reviewing examiner. The examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's left brachial nerve damage began during service or is otherwise causally related to any incident of service, to include in-service exposure to petroleum fuel. The examiner should also offer an opinion as to whether the Veteran's left brachial nerve damage is caused or aggravated by her now service-connected left breast segmental resection/lumpectomy, with left axillary lymph node extraction. If the examiner determines that there has been aggravation as a result of the left breast segmental resection/lumpectomy, with left axillary lymph node extraction, the examiner should report the baseline level of severity of the left brachial nerve damage prior to the onset of aggravation, or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. The examiner should specifically address the July 2007 VA examiner's statement that the brachial nerve damage resulted from "injury during the left breast surgery" and provide an opinion as to whether any such nerve damage was the necessary result of the required surgery. In offering any opinion, the examiner must consider the full record, to include the Veteran's post-service treatment and contentions. The rationale for any opinion offered should be provided. 5. After obtaining the above medical opinion, if the above examiner is not qualified to render an opinion as to gall bladder extraction, the Veteran's claims file should be provided to an appropriate VA examiner to determine the nature and etiology of her gall bladder extraction. The full claims file, to include a copy of this Remand, must be made available to, and be reviewed by, the examiner. Any indicated evaluations, studies, and tests should be conducted, to include an examination if deemed necessary by the reviewing examiner. The examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's gall bladder extraction is causally related to any incident of service, to include her in-service exposure to petroleum. The examiner should refer to her service records as well as to the July 2007 VA examination and January 2013 expert opinion as well as to the research/treatise evidence submitted by the Veteran. In offering any opinion, the examiner must consider the full record, to include the Veteran's contentions. The rationale for any opinion offered should be provided. 6. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs