Citation Nr: 1327305 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 09-13 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for right tonsil squamous cell carcinoma, claimed as respiratory cancer and claimed as non-Hodgkin's lymphoma, to include as due to herbicide exposure and to include as secondary to service-connected prostate cancer. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1963 to January 1967 and from August 1967 to June 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which determined that new and material evidence was not received to reopen a claim for entitlement to service connection for right tonsil squamous cell carcinoma. In April 2012, the Board reopened the claim of entitlement to service connection for right tonsil squamous cell carcinoma, claimed as respiratory cancer, due to herbicide exposure, and remanded the claim for additional development. In December 2012 and February 2013, the Veteran and his representative submitted additional evidence directly to the Board concerning the issue on appeal. As the Veteran had previously submitted a waiver of initial RO consideration of any evidence submitted subsequent to certification of the appeal, this evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). 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. The evidence of record demonstrates that the Veteran served in the Republic of Vietnam, and therefore, in-service exposure to herbicide agents is conceded. 2. The probative, competent evidence of record does not demonstrate that the Veteran's right tonsil squamous cell carcinoma is a disease for which presumptive service connection is warranted based on in-service exposure to herbicide agents. 3. The evidence of record does not establish that the Veteran experienced chronic symptoms relating to right tonsil squamous cell carcinoma during service or continuous symptoms since separation from service. 4. The evidence of record does not show that the Veteran's right tonsil squamous cell carcinoma manifested to a compensable degree within one year of separation from service. 5. The probative, competent evidence of record does not demonstrate that the Veteran's right tonsil squamous cell carcinoma is causally or etiologically related to service. 6. The probative, competent evidence of record does not demonstrate that the Veteran's right tonsil squamous cell carcinoma is causally or etiologically related to his service-connected prostate cancer or that it was aggravated by the service-connected prostate cancer. CONCLUSION OF LAW Right tonsil squamous cell carcinoma was not incurred in or aggravated by service, may not be presumed to have been incurred in service, to include as due to exposure to herbicides, and was not caused or aggravated by service-connected prostate cancer. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.313 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the veteran of any information and 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 veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that VCAA notice as required by 38 U.S.C. § 5103(a) must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. In addition, the notice requirements apply to all five elements of a service connection claim, including: (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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman, 19 Vet. App. at 486. Here, the record shows that letters dated in September 2005 and February 2008 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Dingess/Hartman, 19 Vet. App. 473. The Board also finds that the duty to assist the Veteran has been satisfied in this case. The record includes service treatment records, VA examination reports, VA treatment records, private treatment records, and lay evidence. In the April 2012 decision and remand, the Board reopened the Veteran's claim and remanded it to obtain a medical opinion. Accordingly, in May 2012, the Veteran's claims file was forwarded for a VA medical opinion. However, because the May 2012 opinion did not comply with the Board's remand directives, the Board remanded the Veteran's claim in March 2013. In pertinent part, the Board directed that an oncologist review the claims file, to include a January 2008 letter from Dr. M. Lanasa, and clarify the precise location of where the Veteran's primary cancer developed. In addition, the Board directed that the oncologist address the argument that the Veteran's right tonsil squamous cell carcinoma was one of several types of non-Hodgkin's lymphoma. The record demonstrates that a qualified internist reviewed the Veteran's claims file in April 2013, commented on the January 2008 letter from Dr. M. Lanasa, and provided complete opinions with respect to all theories of entitlement involved in this case. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds the April 2013 opinion to be sufficient and adequate for purposes of determining service connection. In addition, the Board finds the AMC substantially complied with the April 2012 and March 2013 remand directives with respect to the issue on appeal. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). There is no indication in the record that any additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. All of the evidence in the Veteran's claims file has been thoroughly reviewed. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matter decided herein. The Veteran should not assume that pieces of evidence, not explicitly discussed, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). The Veteran asserts that his right tonsil squamous cell carcinoma is the result of in-service exposure to herbicide agents. Specifically, the Veteran and his representative contend that the Veteran's right tonsil squamous cell carcinoma is a respiratory cancer for which presumptive service connection is warranted. In addition, the Veteran's representative asserts right tonsil squamous cell carcinoma is one of several types of non-Hodgkin's lymphoma for which presumptive service connection may be granted. In the alternative, a February 2006 written statement shows the Veteran asserts that his right tonsil squamous cell carcinoma is related to his service-connected prostate cancer. Finally, the Veteran contends that his right tonsil squamous cell carcinoma was not the result of his history of smoking. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, service connection may be established on a secondary basis for a disability that is shown to be proximately due to or the result of a 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) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). In addition, malignant tumors will be presumed to have been incurred in or aggravated by service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The law also provides that "a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307. For purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307(a)(6)(iii), "service in the Republic of Vietnam" means that a veteran must have been present within the land borders of Vietnam to obtain the benefit of the presumption of herbicide exposure. See Haas v. Peake, 525 F.3d 1168, 1197 (Fed. Cir. 2008). Section 3.307(d)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(d)(6)(i). Agent Orange is generally considered an herbicide agent and will be so considered in this decision. If a Veteran was exposed to an herbicide agent during active military, naval, or air 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 such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also 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, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea) and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The Veteran's service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of cancer, to include right tonsil squamous cell carcinoma. An August 2005 VA surgical operation note reflects a diagnosis of tonsillar cancer. The findings were firm three to four centimeter right tonsillar mass involving anterior pillar, and the pathology noted was right tonsil. A September 2005 VA treatment record shows the Veteran was referred for concurrent chemotherapy with XRT for locally advanced squamous cell carcinoma of the head and neck. The assessment was squamous cell carcinoma of right tonsil. In November 2005, a VA physician, Dr. J. Oleson, found it significant that the Veteran reported smoking two packs per week for 30 years. A December 2005, a VA physician noted that the Veteran's past prostate cancer was considered related to Agent Orange exposure; however, his tonsillar cancer was not as clear. While cancers of the respiratory tract were presumed Agent-Orange related; other head, neck, and oral cancers were not automatically considered so. A February 2006 VA treatment record shows the Veteran asked the attending physician whether the tumor could be related to Agent Orange. The physician stated that she could not exclude that as a potential cause since it was accepted that Agent Orange could cause tumors of the respiratory tract. In support of the Veteran's claim, his representative submitted a January 2008 letter from Dr. M. Lanasa, a fellow of hematology and medical oncology. In the January 2008 letter, Dr. Lanasa clarified that the Veteran's history of smoking involved approximately two packs per week, rather than two packs per day as previously referenced, for over 30 years, and stated that this was a considerable and biologically relevant reduction. In addition, Dr. Lanasa noted that although squamous cell carcinoma of the oropharynx (e.g. tonsil) and squamous cell carcinoma of the hypopharynx (respiratory tract) were biologically identical diseases, only cancers of the hypopharynx were considered Agent-Orange related. Dr. Lanasa found this VA distinction arbitrary and noted that the epidemiologic data that showed an association to Agent Orange did not consider the biologic similarities between the cancers. Dr. Lanasa explained that the Veteran had extensive lymph node metastasis at the time of surgery, including involved lymph nodes at levels 2 and 3. According to Dr. Lanasa, Level 3 lymph nodes followed the internal jugular vein and were between the carotid bifurcation and the omohyoid and typically implied metastasis from a hypopharyngeal or supraglottic larynx primary. This pattern of nodal metastasis was shared between the tonsillar and hypopharyngeal squamous cell cancers and could even imply a synchronous occult hypopharyngeal primary. In May 2012, the Veteran's claims file was forwarded for a medical opinion with respect to the nature and etiology of the Veteran's right tonsil squamous cell carcinoma. The medical report indicates the Veteran's claims file was reviewed by a physician's assistant. Based on a review of the record, the physician's assistant opined that the Veteran's claimed respiratory cancer was a primary cancer of the neck lymph nodes. The physician's assistant also opined that the Veteran's cancer was unrelated to his service-connected prostate cancer and that his cancer was not aggravated by his prostate cancer. The physician's assistant reported that the etiology of the Veteran's cancer was implied as due to smoking and cited the November 2005 VA treatment record. The physician's assistant found that Dr. Oleson's statements indicated that smoking was the likely cause of the Veteran's neck cancer. The physician's assistant also cited a report, "Veterans and Agent Orange: Update 2008," which stated that there was inadequate or insufficient information to determine whether there was an association between exposure to the chemicals of interest and basal-cell or squamous cell cancer. The physician's assistant also noted a consensus report regarding the health effects in Vietnam Veterans of exposure to herbicides and cited multiple studies concerning the association of squamous cell carcinoma to smoking. In November 2012, the Veteran submitted a written statement in support of his claim. The Veteran reported that he had been in the Dental Technology field for the past 40 years and that he had seen a significant increase in cases of mouth, throat, and tonsil cancer in the past five to ten years. The Veteran stated that many of the patients were Vietnam Veterans who had been exposed to Agent Orange. The Veteran also stated that some of the patients were smokers but many did not smoke. The Veteran therefore asserted that his form of cancer was not always connected to smoking and that in many cases it was connected to Agent Orange exposure. The Veteran argued that his history of smoking was not relevant, as he had been a very light smoker, and asserted that his in-service exposure to Agent Orange had greater relevance. The Veteran also submitted a November 2012 letter from Dr. N. Leonard in support of his claim. Dr. Leonard reported that he had known the Veteran for over 30 years and that he had no recollection of the Veteran smoking cigarettes in his presence. He stated that the Veteran had quit smoking about eight years ago. In addition, the Veteran submitted a November 2012 letter from D. Greve, who reported that he had served with the Veteran in Vietnam. He stated that he had never witnessed the Veteran smoking cigarettes in large quantities and that the Veteran's work as a dental technician limited his time to smoke. The Veteran also submitted several internet articles concerning cancers of the head and neck and the effects of smoking and an internet article reporting that tonsils were lymph tissues associated with the respiratory system. Pursuant to the March 2013 remand, the Veteran's claims file was forwarded to a qualified internist for an additional medical opinion. After reviewing the Veteran's claims file, the VA examiner reported that the Veteran had two primary cancers, one in the right tonsil and one in the prostate. The VA examiner stated that the Veteran's primary tonsillar cancer was not any type of non-Hodgkin's lymphoma. In support of the opinion, the VA examiner cited a July 2005 CT scan, an August 2005 laryngoscopy, esophagoscopy, right tonsillectomy report, an August 2005 surgical operative report, an August 2005 anatomic pathology report of the right tonsil, and a July 2011 oncology report. The VA examiner stated that the Veteran's squamous cell carcinoma arose in the lining of the tonsil with equivalent, healthy cell being a squamous cell. The VA examiner reported that such cells line areas of the body exposed to the exterior, including the skin, oral cavity, esophagus, nose, and anus. The bulk of the tonsil is lymphoid tissue from which lymphomas arise. The cell is of a very different nature to squamous cells, and the lymph cell functions included defense against infection and cancers. The VA examiner found the Veteran did not have any type of lymphoma. In addition, the VA examiner noted that the January 2011 reference to carcinoma in situ of trachea was an erroneous entry in the medical record, as the VA physician who recorded the January 2011 VA treatment record clarified that carcinoma of the tonsil was the intended diagnosis. The April 2013 VA examiner also opined that the Veteran's carcinoma of the tonsil was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that the Veteran's exposure to herbicide agents had been conceded and that VA granted benefits for veterans who developed respiratory cancers involving the lungs, trachea, larynx, and bronchus. However, squamous carcinoma of the tonsil was not in the group of respiratory cancers. In addition, the VA examiner cited reports of the Institute of Medicine on the health effects of Agent Orange and similar herbicides. As of the most recent update in 2010, there was inadequate/insufficient evidence to determine whether an association existed between exposure to herbicides and mouth, throat, and sinus cancers. Concerning service connection on a secondary basis, the VA examiner opined that the Veteran's carcinoma of the tonsil was less likely than not incurred in or caused by his service-connected prostate cancer. The VA examiner stated that there was no cause and effect relationship between prostate cancer and carcinoma of the tonsil. Prostate cancer did not spread to the tonsil. Prostate cancer is an adenocarcinoma that arises from glandular cells, while tonsillar carcinoma arises from squamous cells. The VA examiner reported that some known factors that cause cancer include oncogenic viruses, genetic factors, chemicals, immune deficiency, and chronic irritation and injury. When two or more cancers exist in the same patient, the VA examiner reported that they could have a common cause. However, one cancer was never the cause of the other cancers. With respect to Dr. Lanasa's letter, the VA examiner agreed that a tumor of the hypopharynx would drain to the same area as the drainage from tonsils. However, the medical facts in the Veteran's case clearly identified the tonsil as the location of the primary cancer. The VA examiner reported that the identified primary tumor was confined to the right tonsil and did not extend above or below its confines except by lymphatic drainage to the regional nodes. According to the VA examiner, this was also corroborated by the absence of any mass lesion on CT scan in the soft tissues of the neck outside of the lymph nodes. In addition, the tonsillar cancer was three centimeters in diameter, and there was no evidence of a mass lesion in the hypopharynx on direct examination, CT scan, or on dissection of the neck during surgery. The VA examiner therefore found it was clear that the site of origin was the tonsil where the bulk of the tumor was found. The VA examiner reported that a diagnosis of cancer of the hypopharynx required direct visualization best done in the operating room and imaging by CT scan, which were performed in the Veteran's case, and opined that the findings in the Veteran's case were not consistent with disease of the hypopharynx. Here, the evidence of record demonstrates that the Veteran was present within the land borders of Vietnam during the Vietnam era. Therefore, he is presumed to have been exposed to herbicide agents for service connection purposes. However, the probative, competent evidence of record does not demonstrate that the Veteran's right tonsil squamous cell carcinoma is a disease for which presumptive service connection is warranted under VA regulations. First, the Board notes that squamous cell carcinoma of the tonsil is not among the specific listed conditions subject to presumptive service connection based on herbicide exposure under 38 C.F.R. § 3.309(e). Despite the Veteran and his representative's assertions that tonsil cancer should be considered a "respiratory cancer" under this regulation, the Board finds that it is not a respiratory cancer under the governing regulation, which defines respiratory cancers as including only the following: cancer of the lung, bronchus, larynx, or trachea. 38 C.F.R. § 3.309(e). Significantly, the Secretary of VA has explicitly determined that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for cancers of the oral cavity (including lips and tongue), pharynx (including tonsils), or nasal cavity (including ears and sinuses). Furthermore, the Board finds the April 2013 VA examiner's opinion carries significant probative value with respect to the precise location of where the Veteran's primary cancer developed. The April 2013 VA examiner cited multiple medical records that showed the Veteran's primary tumor was confined to the right tonsil and did not extend above or below its confines except by lymphatic drainage to the regional nodes. In addition, there was no evidence of a mass lesion in the hypopharynx on direct examination, CT scan, or on dissection of the neck during surgery, and the VA examiner stated it was clear that the site of origin was the tonsil where the bulk of the tumor was found. The VA examiner reported that a diagnosis of cancer of the hypopharynx required direct visualization best done in the operating room and imaging by CT scan and that the findings were not consistent with disease of the hypopharynx. The Board acknowledges Dr. Lanasa's opinion that squamous cell carcinoma of the oropharynx and squamous cell carcinoma of the hypopharynx are biologically identical diseases and that he found VA's distinction arbitrary. However, as stated above, the Secretary of VA has explicitly determined that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for cancers of the oral cavity, pharynx, or nasal cavity. In addition, although it appears that Dr. Lanasa had access to the Veteran's medical records, the Board finds Dr. Lanasa's opinion was premised on general, medical principles and was inconclusive as a result. For example, Dr. Lanasa reported that Level 3 lymph nodes "typically implied metastasis from a hypopharyngeal or supraglottic larynx primary." In addition, Dr. Lanasa commented that the pattern of nodal metastasis was shared between the tonsillar and hypopharyngeal squamous cell cancers and "could even imply a synchronous occult hypopharyngeal primary." In this respect, the Court has held that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. Jones v. Shinseki, 23, Vet. App. 382, 389-90 (2010). Applicable regulations also provide that a finding of service connection may not be based on a resort to speculation or a remote possibility. See 38 C.F.R. § 3.102 (2012). Because Dr. Lanasa's statements are phrased with inconclusive terminology, the Board finds the opinion carries less probative value than the opinion provided by the April 2013 VA examiner. In addition, the Board acknowledges the representative's assertions that the Veteran's right tonsil squamous cell carcinoma is one of several types of non-Hodgkin's lymphoma for which presumptive service connection may be granted. Again, the Board finds the April 2013 VA examiner's opinion probative with respect to the nature of the Veteran's claimed condition. The VA examiner stated that the Veteran's primary tonsillar cancer was not any type of non-Hodgkin's lymphoma and explained that the Veteran's condition arose in the lining of the tonsil with equivalent healthy cell being a squamous cell. The VA examiner reported that the bulk of the tonsil was lymphoid tissue from which lymphomas arise, and the cell was of a very different nature to squamous cells. The VA examiner found the Veteran did not have any type of lymphoma. It is well known that a layperson without medical training is not qualified to render a medical diagnosis or medical opinion concerning the etiology of a cancer, to include right tonsil squamous cell carcinoma. See 38 C.F.R. § 3.159(a)(1). In certain unique instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Here, however, the Board finds the nature and etiology of right tonsil squamous cell carcinoma is not something for which a layman is competent to provide an opinion. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (noting that lay testimony is competent to establish observable symptomatology but not competent to establish medical etiology or render medical opinions). Although the evidence shows that the Veteran has been in the Dental Technology field for the past 40 years, the Board does not find that the Veteran or his representative possesses the requisite training or credentials needed to render a competent opinion as to the nature of right tonsil squamous cell carcinoma. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). As such, the lay opinions provided by the Veteran and his representative do not constitute competent medical evidence and lack probative value. Second, the Veteran's service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of cancer, to include right tonsil squamous cell carcinoma. The Board acknowledges that in some circumstances, if there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Here, however, the competent evidence of record indicates that the Veteran was first diagnosed with right tonsil squamous cell carcinoma in August 2005, approximately 26 years following his separation from service. 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). In addition, the Veteran does not assert that he experienced symptoms of right tonsil squamous cell carcinoma during service or that he has experienced continuous symptoms since his separation from service. Thus, the evidence does not indicate that right tonsil squamous cell carcinoma manifested to a compensable degree within the year following active duty. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As such, the Board finds the Veteran is not entitled to service connection for right tonsil squamous cell carcinoma on a presumptive basis. With respect to entitlement to service connection on a direct basis, the record reflects a diagnosis of right tonsil squamous cell carcinoma during the pendency of the appeal, and therefore the Board finds the Veteran has established a current disability. However, with respect to the second element of a claim for direct service connection, the Veteran's service treatment records do not demonstrate complaints of, treatment for, or a diagnosis of any cancer, to include cancer of the right tonsil. In addition, the April 2013 VA examiner opined that the Veteran's carcinoma of the tonsil was less likely than not incurred in or caused by the claimed in-service injury, event, or illness and provided a complete rationale for the opinion based on the evidence of record. Further, as stated above, the evidence does not demonstrate that the Veteran experienced chronic symptoms during service or continuous symptoms since separation from service. Moreover, the Veteran and his representative appear to only contend that his right tonsil squamous cell carcinoma was the result of in-service exposure to herbicides. Even if the Veteran were to assert that right tonsil squamous cell carcinoma was directly related to active duty, again the Board finds that a layperson without medical training is not qualified to render a medical diagnosis or medical opinion concerning the etiology of a cancer such as right tonsil squamous cell carcinoma. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). As stated above, the evidence does not show that the Veteran or his representative possesses the requisite training or credentials needed to render a competent opinion as to the medical causation of right tonsil squamous cell carcinoma. Grottveit, 5 Vet. App. at 93. Concerning service connection on a secondary basis, the evidence must show that the current disability was either caused or aggravated by a service-connected disability. Harder v. Brown, 5 Vet. App. 183, 187-89 (1993). Here, the Veteran asserts that his right tonsil squamous cell carcinoma was caused or aggravated by his service-connected prostate cancer. However, the competent, clinical evidence of record is against a finding that the Veteran's right tonsil squamous cell carcinoma was caused or aggravated by his prostate cancer. In May 2012, the physician's assistant opined that the Veteran's cancer was unrelated to his service-connected prostate cancer and that his cancer was not aggravated by his prostate cancer. In addition, the April 2013 VA examiner opined that the Veteran's carcinoma of the tonsil was less likely than not incurred in or caused by his service-connected prostate cancer. The VA examiner stated that there was no cause and effect relationship between prostate cancer and carcinoma of the tonsil and that prostate cancer did not spread to the tonsil. According to the VA examiner, prostate cancer is an adenocarcinoma that arises from glandular cells, whereas tonsillar carcinoma arises from squamous cells. The VA examiner reported that one cancer is never the cause of the other cancers. Again, the Board acknowledges that the Veteran is competent to describe his symptoms. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, a veteran's own conclusion stated in support of his claim that his present disability is secondary to his service-connected disability is not competent evidence as to the issue of medical causation of right tonsil squamous cell carcinoma. See 38 C.F.R. § 3.159; see also Grivois v. Brown, 6 Vet. App. 136 (1994). Thus, a medical opinion is needed to connect one medical condition to another medical condition. In this case, the probative, competent evidence of record provides negative opinions concerning a nexus between the Veteran's right tonsil squamous cell carcinoma and his service-connected prostate cancer. Based on the foregoing, the Board finds that the preponderance of the evidence is against a grant of service connection for right tonsil squamous cell carcinoma, to include as due to in-service herbicide exposure and to include as secondary to service-connected prostate cancer. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to service connection for right tonsil squamous cell carcinoma, claimed as respiratory cancer and claimed as non-Hodgkin's lymphoma, to include as due to herbicide exposure and to include as secondary to prostate cancer, is denied. ____________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs