Citation Nr: 1324853 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 12-00 559 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for esophageal cancer as a result of exposure to ionizing radiation. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. M. Donahue, Associate Counsel INTRODUCTION The Veteran served in the United States Army from April 1956 to March 1959. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that denied the benefits sought on appeal. The issues were previously remanded in November 2012 and December 2012 for additional development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Esophageal cancer was not incurred in service and is not due to exposure to ionizing radiation in service. 2. The Veteran is service connected for tinnitus, rated as 10 percent disabling, and hearing loss, rated as noncompensable. The Veteran does not meet the combined schedular requirements for TDIU. 3. The Veteran's service-connected disabilities, standing alone, are not of such severity so as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. Service connection for esophageal cancer is not established. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309, 3.311 (2012). 2. The criteria for a TDIU have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16, 4.18, 4.19, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2008); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the appellant pre-adjudication notice by letters dated in October 2010 and February 2011. The February 2011 letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment and personnel records have likely been destroyed in a 1973 fire at the National Personnel Records Center (NPRC) in St. Louis, Missouri. In September 2010, the RO prepared a memorandum addressing the unavailability of the service treatment records and the Veteran was made aware of the unavailability of these records and has been provided with information as to alternate documents that might substitute for the service treatment records. The Board notes that in an April 2011 Defense Threat Reduction Agency report indicated that some records concerning the Veterans location during active service were reconstructed from unit morning reports. The United States Court of Appeals for Veterans Claims (hereinafter 'the Court') has held that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted, the RO developed this case pursuant to the provisions of 38 C.F.R. § 3.311, and such development included obtaining an appropriate medical opinion the Under Secretary for Health, delegated to the Director of the Post 9-11 Era Environmental Health Program. The Board finds that opinion obtained in this case is adequate. It is predicated on a substantial review of the relevant evidence, particularly of his in-service radiation exposure and subsequent assessment of esophageal cancer. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the service connection issue addressed in this decision has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Given the March 2013 Director of the Post 9-11 Era Environmental Health Program memorandum opinion and the subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its November and December 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). I. Service Connection Claim Factual Background The Veteran contends that he was exposed to ionizing radiation during the summers of 1957 and 1958 while serving at White Sands Proving Grounds (White Sands) in New Mexico. More specifically, the Veteran argues that he was exposed to residual radiation from atomic testing conducted at White Sands as part of project TRINITY. The Veteran has also asserted that he was exposed to radiation when he was assigned to guard nuclear missiles in Italy. An October 2010 VA progress note indicates that he Veteran was diagnosed with esophageal adenocarcinoma in August 2008. The Veteran was treated with surgery. In August 2010, the adenocarcinoma recurred. The diagnosis was metastatic stage IV esophageal adenocarcinoma. In a February 2010 letter, K. D., M.D., reported that the Veteran recently completed a course of palliative radiotherapy for metastatic esophageal cancer and is undergoing chemotherapy for the same. The Veteran described a history of exposure to radiation while serving in the military. Knowing the cause of cancer for any individual is difficult if not impossible. However, based on his knowledge of the Veteran as his treating physician and his expertise in the area, he opined that the Veteran's cancer was contributed to or caused by his exposure to radiation while he was in the military. The physician went on to state that while there are many causes of cancer, the Veteran's exposure to significant levels of radiation while in White Sands area and his knowledge of the Veteran's case generally lead him to the conclusion that it is at least as likely as not that the Veteran's cancer was contributed to or caused by exposure to radiation while in the White Sands area between 1957 and 1958. Evidence supporting the role of radiation in esophageal cancer comes from studies of radiation exposure for survivors of Hiroshima and Nagasaki. These studies show radiation exposure is associated with a higher risk of developing many types of cancer, including esophageal cancer. Several research articles have shown elevated cancer rates following exposure. In an April 2011 letter, the Army Dosimetry Center reported that they researched the file for records of exposure to ionizing radiation for the Veteran; however, no records were located. In an April 2011 letter, the United States Defense Threat Reduction Agency (DTRA) noted that as of January 1, 1957, the Veteran was assigned to Detachment 2, United States Army Garrison, Verona, Italy. On May 17, 1957, the Veteran was transferred to and joined Firing Battery, 543rd Field Artillery Battalion at Vicenza, Italy. On August 23, 1957, the Veteran was assigned temporary duty (TDY) with the 1st Guided Missile Brigade at Fort Bliss, Texas. The Veteran returned to duty in Italy on September 16, 1957. On June 23, 1958, the Veteran's unit was redesignated the 1st Missile Battalion, 82nd Field Artillery Regiment at Vicenza. On July 15, 1958, the Veteran was again assigned TDY at Fort Bliss, Texas. The Veteran returned to duty with his unit at Vicenza on August 5, 1958. The Veteran remained assigned to his unit at Vicenza until March 8, 1959, when he was transferred to further duty at Leghorn, Italy. The DTRA acknowledged the Veteran's contentions that he served at White Sands, but also noted that with the exception of the 1945 TRINITY project, which was indeed conducted at White Sands, all continental atmospheric nuclear testing was conducted at the Nevada Test Site. Additionally, after a careful search of available dosimetry data, the DTRA was unable to find a record of radiation exposure for the Veteran. Instead, the DTRA noted that it was possible that the Veteran may have participated in a simulated nuclear test exercise at White Sands. In simulations of this nature, the DTRA noted, all aspects of the exercise (clothing worn, film badges, special missions, etc.) were the same as at an actual detonation. There would have been no potential for exposure to radiation at such test exercises. In summary, the DTRA found that historical records did not document the Veteran's participation in atmospheric nuclear testing. As a result, DTRA made no attempt to provide a dose estimate with respect to the Veteran's possible radiation exposure. In May 2011, the Veteran submitted a statement disagreeing with the DTRA assessment. He asserted that he was only at Fort Bliss temporarily on his way to White Sands, and that he was on duty in White Sands in 1957 and 1958. He does not claim that he was involved in the on-site participation in a nuclear test. Instead, the Veteran asserts that he was exposed to radioactive materials that remained on the ground years after the test. He reported no one in his family has a history of esophageal cancer. In a July 2011 letter, K. D., M.D., reported that the risk of developing esophageal cancer is increased following radiation exposure as seen in populations exposed to radiation. One characteristic of radiation induced malignancy is a relatively long latency period after exposure, where there is no increased risk. The latency period is typically 5 years. Following the latency period, the risk of developing a cancer increased with each passing year. It is a cumulative risk. The increased risk over increasing time since exposure has been well described for both bomb blast and treatment survivors. The physician reported that current thought on this topic is that radiation exposure generates genetic damage that takes years to evolve into clinically evident cancer. In May and August 2011 statements, the Veteran asserted he had a number of duties that may have increased his exposure to radiation to include Staff Duty Driver personnel to various locations, and guarding the nuclear missiles in Italy. The Veteran also claimed that he had a Top Secret Clearance which allowed him to be responsible for nuclear codes. In November 2012, the Veteran submitted a DNA profile which indicated that he has moderately lower odds of esophageal cancer. In March 2013, the Director of the Post 9-11 Era Environmental Health Program submitted a memorandum. The physician found that there is no record of radiation dose available on the record and letters from the Army Dosimetry Center and DTRA do not provide an estimate of radiation dose nor confirm participation in any nuclear testing activity. In normal circumstances, military personal are given radiation dosimetry when it is expected that their radiation exposure will exceed 0.5 rem per year. Since none of the Veteran's duties would be expected to give him a radiation dose exceeding this amount, he was not monitored for radiation exposure. The Veteran was assigned a dose of 1.5 rem for his time in the military service. The physician found that this dose estimate is a high-sided estimate, and one which gives the Veteran great benefit of the doubt concerning his statements about exposure to ionizing radiation during service. The Health Physics Society, in a position statement, states that "in accordance with current knowledge of radiation health risks, the Health Physics Society recommends against quantitative estimation of health risks below an individual dose of 5 rem in one year or a lifetime dose of 10 rem above that received from natural sources." The position statement goes on to say that "there is substantial and convincing scientific evidence for health risks following high-dose exposures. However, below 5-10 rem (which includes occupational and environment exposures, risks of health effects are either too small to be observed or nonexistent." Since the Veteran's radiation dose did not exceed 5 rem in one year or 10 rem in a lifetime, it is his opinion that it is unlikely that the Veteran's esophageal cancer with metastases to the bone can be attributed to radiation exposure while in military service. In an April 2013 statement, the Director of Compensation Service agreed with the March 2013 memorandum, and found that as a result of the opinion, and following review of the evidence in its entirety, it is his opinion that there is no reasonable possibility that the Veteran's esophageal cancer with metastases to the bone resulted from radiation exposure in service. Laws and Regulations Veterans are entitled to compensation from VA if they develop a disability 'resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty.' 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Holton v. Shinseki, 557 F.3d 1362 (2009). The absence of any one element will result in the denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). The Veteran claims his esophageal cancer was a result of radiation exposure during service. Service connection for a disorder which is claimed to be attributable to radiation exposure during service can be accomplished in three different ways. See Ramey v. Brown, 9 Vet. App. 40 (1996). First, direct service connection must be considered by way of in-service incurrence or aggravation therein, including presumptive service connection for chronic diseases. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Second, if a Veteran participated in service in a radiation-risk activity (as defined by statute and regulation), and after service developed one of certain enumerated cancers, it will be presumed that the cancer was incurred in service. 38 U.S.C.A. § 1112(c) (West 2002); 38 C.F.R. § 3.309(d) (2012). Third, if a Veteran was exposed in service to ionizing radiation, and after service, developed one of the specifically enumerated diseases within a period specified for each by law, then his claim is referred to the Under Secretary for Benefits who must determine, based on the extent of the exposure, whether there is a reasonable possibility that the disease was incurred in service. 38 C.F.R. § 3.311 (2012). A 'radiation exposed Veteran' is one who, while serving on active duty or on active duty for training or inactive duty for training, participated in a radiation-risk activity. 'Radiation-risk activity' is defined to mean on site participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan, or Nagasaki, Japan, by United States Forces during the period beginning on August 6, 1945, and ending July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupation forces in Hiroshima or Nagasaki during the period beginning on August 6, 1945, and ending on July 1, 1946. 38 C.F.R. § 3.309 (2012). Diseases subject to presumptive service connection based on participation in a 'radiation-risk activity' are the following: (i) leukemia (other than chronic lymphocytic leukemia); (ii) cancer of the thyroid; (iii) cancer of the breast; (iv) cancer of the pharynx; (v) cancer of the esophagus; (vi) cancer of the stomach; (vii) cancer of the small intestine; (viii) cancer of the pancreas; (ix) multiple myelomas; (x) lymphomas (except Hodgkin's disease); (xi) cancer of the bile ducts; (xii) cancer of the gall bladder; (xiii) primary liver cancer (except if cirrhosis or hepatitis B is indicated); (xiv) cancer of the salivary gland; (xv) cancer of the urinary tract; (xvi) bronchial alveolar carcinoma; (xvii) cancer of the bone; (xviii) cancer of the brain; (xix) cancer of the colon; (xx) cancer of the lung; and (xxi) cancer of the ovary. 38 C.F.R. § 3.309(d) (2) (2012). 38 C.F.R. § 3.311 provides instruction in the development of claims based on exposure to ionizing radiation. Pursuant to 38 C.F.R. § 3.311 'radiogenic disease' is defined as a disease that may be induced by ionizing radiation including those enumerated under the regulation, which includes skin cancer and non-malignant thyroid nodular disease. 38 C.F.R. § 3.311(b)(2) (xxiii) (2012). The United States Court of Appeals for the Federal Circuit has held that when a Veteran is found not to be entitled to a regulatory presumption of service connection for any given disability, the claim must nonetheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F. 3d 1039, 1043-1044 (Fed. Cir. 1994). Thus, the Board must not only determine whether the Veteran has a disability that is recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether the disability is otherwise the result of active service. Analysis As an initial matter, the Board notes that the Veteran has not alleged that the claimed disability was incurred in combat. Therefore, the provisions of 38 U.S.C.A. § 1154(b) (West 2002) are not for application. First, the Board finds that service connection under 38 C.F.R. § 3.309(d), for diseases specific to radiation-exposed veterans is not warranted. The Board notes that esophageal cancer is a disease that may be presumptively service connected for radiation-exposed veterans. However, the Veteran does not meet the criteria for a 'radiation exposed Veteran' as there is no evidence that he participated in a radiation-risk activity as defined by 38 C.F.R. § 3.309. Therefore, presumption is not warranted in this case. Under the criteria of 38 C.F.R. § 3.311, esophageal cancer is considered a radiogenic disease. Therefore, pursuant to the provisions of 38 C.F.R. § 3.311, the Veteran's claim was referred to obtain a dose estimate and for an opinion as to the likelihood that his claimed disability was related to exposure to ionizing radiation in service. As noted, this case was referred to the Under Secretary of Health who delegated the responsibility of obtaining the requested information to the Director of the Post 9-11 Era Environmental Health Program. The physician determined that there is no record of radiation dose available on the record and that the letters from the Army Dosimetry Center and DTRA do not provide an estimate of radiation dose nor confirm participation in any nuclear testing activity. It was noted that in normal circumstances, military personal are given radiation dosimetry when it is expected that their radiation exposure will exceed 0.5 rem per year. Since none of the Veteran's duties would be expected to give him a radiation dose exceeding this amount, he was not monitored for radiation exposure. Given this history, the Veteran was assigned a dose of 1.5 rem for his time in the military service. The physician explained that this dose estimate is a high-sided estimate, and one which gives the Veteran great benefit of the doubt concerning his statements about exposure to ionizing radiation during service. It was noted that the Health Physics Society, in a position statement, states that "in accordance with current knowledge of radiation health risks, the Health Physics Society recommends against quantitative estimation of health risks below an individual dose of 5 rem in one year or a lifetime dose of 10 rem above that received from natural sources." The position statement goes on to say that "there is substantial and convincing scientific evidence for health risks following high-dose exposures. However, below 5-10 rem (which includes occupational and environment exposures, risks of health effects are either too small to be observed or nonexistent." Since the Veteran's radiation dose did not exceed 5 rem in one year or 10 rem in a lifetime, it is his opinion that it is unlikely that the Veteran's esophageal cancer with metastases to the bone can be attributed to radiation exposure while in military service. The Director of Compensation Service subsequently reviewed this memorandum, and found that as a result of the opinion, and following review of the evidence in its entirety, there is no reasonable possibility that the Veteran's esophageal cancer with metastases to the bone resulted from radiation exposure in service. As such, service connection for esophageal cancer is not available pursuant to the provisions of 38 C.F.R. § 3.311. The Board does note that, when necessary to reconcile a material difference between appellant's estimate of dose from a credible source, and dose data derived from official military records, the estimates and supporting documentation shall be submitted to an independent expert, selected by the Director of the National Institutes of Health (NIH), who shall prepare a separate radiation dose estimate for consideration in adjudication of the claim. Here, as will be discussed in greater detail, the Veteran has submitted statements from a private physician in support of the appeal. Nevertheless, the Board finds referral to an independent expert is unnecessary as the Veteran's private physician did not submit an alternative radiation dosage estimate. As to whether the Veteran is entitled to service connection for esophageal cancer disease on a direct basis, the Board finds the opinion of the director of the Post 9-11 Era Environmental Health Program to be the most probative evidence of record. That opinion is supported by substantial medical rationale and is consistent with the Veteran's documented history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). The Board finds substantially less value in the Veteran's private radiation oncologist's opinion that his esophageal cancer is more likely than not related to the Veteran's in-service radiation exposure. Significantly, it does not appear the Veteran's private oncologist was aware of the degree of likely radiation exposure when arriving at his conclusion beyond relying on the Veteran's claim of "significant exposure." Given the nature and circumstances of the Veteran's service, and the detailed explanation provided by the director of the Post 9-11 Era Environmental Health Program in arriving at the dose estimate used, the Board finds that the above mentioned private nexus opinion is based on incomplete, and to a large degree inaccurate, factual evidence. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board must assess the credibility and probative value of the medical evidence in the record); Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion included the physician's access to the claims file and the thoroughness and detail of the opinion); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (holding that the probative value of medical opinion evidence is based on the personal examination of the patient, the knowledge and skill in analyzing the data, and the medical conclusion reached). The Board notes that other than the private opinion discussed and discounted above, there is no competent evidence indicating that the Veteran's esophageal cancer is related to service. There is no lay or medical proof of esophageal cancer during service or within one year of separation. Furthermore, there is no assertion that he had esophageal cancer in proximity to separation from service. The first objective post-service evidence of an esophageal disorder is in an August 2008 private treatment record, approximately 49 years after separation from service. 38 C.F.R. §§ 3.303, 3.308. See also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between service discharge and medical documentation of a claimed disability is evidence against a claim of service connection). Significantly, the record also includes no competent medical opinion establishing a nexus or medical relationship between current esophageal cancer diagnosed post-service and events during the Veteran's active service (other than radiation exposure), and neither the Veteran nor his representative has presented, identified, or alluded to the existence of any such opinion. To the contrary, the medical opinions in the claims file specifically state that the Veteran's esophageal cancer is not related to anything that occurred in the service. The Board also considered the Veteran's DNA profile indicating that he has moderately lower odds of esophageal cancer; however, this report does not give an opinion as to what the etiology is more likely to be and does not relate the Veteran's esophageal cancer to active service. Consequently, the Board finds that entitlement to service connection for esophageal cancer on a direct basis or on the basis of a presumption is not warranted as the preponderance of the evidence is against service connection on those bases. The Board also notes that the Veteran's statements regarding the etiology of esophageal cancer do not constitute competent lay evidence as such a determination is beyond the realm of a layman's competence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There being no competent opinions establishing that esophageal cancer is related to the Veteran's service, the Board finds that service connection must be denied. In conclusion, the preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C.A. § 5107(b), Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). II. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his or her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Under the applicable regulations, benefits based on individual unemployability are granted only when it is established that the service- connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. Under 38 C.F.R. § 4.16, if there is only one such disability, it must be rated at least 60 percent disabling to qualify for benefits based on individual unemployability. If there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background including his or her employment and educational history. 38 C.F.R. §4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In this case, the Board notes that the Veteran is service connected for tinnitus, rated as 10 percent disabling and right hearing loss, rated as noncompensable. As such, his combined rating is 10 percent. Therefore, his service-connected disabilities do not meet the percentage rating standards for TDIU. 38 C.F.R. § 4.16(a). Nevertheless, the Board must consider whether the evidence warrants referral to the appropriate VA officials for entitlement to a total disability rating for compensation purposes based on individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. §4.16(b). See Bowling, 15 Vet. App. at 6. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, the Veteran asserts that he is unable to work because of the severity of his esophageal cancer, which, as noted above, the Board has found is not a service-connected disorder. In light of this finding, and having reviewed the record, the Board finds that the preponderance of the evidence weighs against finding that he is unable to secure or maintain substantially gainful employment due to his service-connected disabilities. The evidence in the file supports that the Veteran cannot work due to his esophageal cancer; however, there is nothing in the file that indicates that the Veteran is unemployable due to his service-connected tinnitus and hearing loss. A March 2011 VA examination indicated that the Veteran's hearing loss does not render him unemployable and the Veteran's tinnitus causes no significant affects on his occupation. The Board finds that the most probative medical evidence of record on the matter is against a finding that the Veteran is unemployable due to his service-connected disabilities so as to warrant referral of the issue of entitlement to TDIU on an extraschedular basis. In summary, while the Board does not doubt that the Veteran's service-connected disabilities have some effect on his employability, the weight of the evidence does not support his contention that his service-connected disabilities are of such severity so as to preclude his participation in any form of substantially gainful employment. The Board believes that the symptomatology associated with the service-connected disabilities is appropriately compensated via the combined 10 percent rating which is currently assigned. Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states: '[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.' See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). Thus, the Board finds that the RO's decision not to refer this issue consideration of TDIU was correct. As such, the benefit of the doubt doctrine is inapplicable, and the claim must be denied. See 38 C.F.R. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for esophageal cancer as a result of exposure to ionizing radiation is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs