Citation Nr: 1327577 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 09-16 384 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL Appellant and R.S. ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is the surviving spouse of a Veteran who served on active duty from January 1966 to May 1970. The Veteran died in May 2007. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Cleveland, Ohio Department of Veterans Affairs (VA) Regional Office (RO). In October 2011, a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the Veteran's claims file. In March 2012 the Board remanded the matter for further development. In November 2012 the appellant requested, and was granted, an extension to submit additional evidence. In April 2013, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during the Vietnam era. 2. The Veteran died in May 2007; his death certificate shows that the cause of his death was pancreatic cancer with liver metastases due to or a consequence of bilateral pulmonary emboli. 3. Pancreatic cancer, liver cancer and pulmonary emboli or any symptoms related thereto were not manifested in service; the cancers were not manifested within a year following the Veteran's separation from active duty; and these disabilities are not shown to have been related to his service (to include as due to exposure to herbicides and/or asbestos therein). 4. The Veteran had not established service connection for any disability during his lifetime; it is not shown that a service-connected disability caused or contributed to cause his death. 5. Type 2 diabetes mellitus and/or coronary artery disease (for which service connection may have been warranted) are not shown to have rendered the Veteran materially less capable of resisting the effects of his death-causing cancers and pulmonary emboli or to otherwise have contributed to his death. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1310 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to this claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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 C.F.R. § 3.159(b)(1). VCAA notice requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In Hupp v. Nicholson, 21 Vet. App. 342 (2007), the United States Court of Appeals for Veterans Claims (Court) held that proper VCAA notice for dependency and indemnity compensation (DIC) claims must also include: (1) a statement of the conditions, if any, for which a Veteran was service-connected at the time of his death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected claim; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service-connected. September 2007 and March 2011 letters (collectively) explained the evidence necessary to substantiate the appellant's claim essentially in accordance with Hupp, the evidence VA was responsible for providing, and the evidence the appellant was responsible for providing. She was advised of effective date criteria, in the March 2011 notice. While the notice letters did not specify that the Veteran had not established service connection for any disability, the appellant is not prejudiced by such omission, as her statements and testimony reflect that she has been aware he had not done so. Further, while the March 2011 letter followed the initial adjudication of this matter, the notice timing defect was cured by subsequent readjudication, in October 2012. In addition, the Board notes that at the hearing before the undersigned the appellant did not receive formal notification of what is needed to substantiate her claim. However, she is not prejudiced by such omission. The arguments and testimony presented at the hearing reflect that the appellant is fully aware that the Veteran had not established service connection for any disability, of what is needed to substantiate a claim of service based on a disability not yet service-connected, and that her claim has been denied because the Veteran's death-causing disabilities were not shown to have been related to his service; her submission, testimony, and arguments address those points. Notably, it has not been alleged that the appellant is prejudiced by a notice defect. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The Veteran's service treatment records (STR's), service personnel records, and private treatment and VA medical records are associated with his claims file. A buddy statement (from A.J.S.) corroborates the Veteran's service in Vietnam and exposure to Agent Orange. The record includes reports of research on the adverse health effects resulting from exposure to herbicides. The appellant was afforded a Travel Board hearing in October 2011. The process of substantiating a claim of service connection for the cause of the Veteran's death was fully explained at the hearing; it was suggested to the appellant that she submit any outstanding evidence regarding the Veteran having heart disease (and its contribution to his death), as well as any additional evidence bearing on a nexus between exposure to herbicides and/or asbestos and the causes of the Veteran's death. Pursuant to the Board's March 2012 remand the RO conducted development to secure private treatment and hospital records. The RO secured a June 2012 medical advisory opinion. The Board thereafter secured a VHA expert medical advisory opinion to address the unresolved medical questions in this matter, and the appellant received a copy and had opportunity to respond. As discussed below, the Board finds the medical evidence now adequate for rating purposes. The Board finds that there has been substantial compliance with its March 2012 remand instructions and the April 2013 request for a VHA medical advisory opinion. The appellant was provided a copy of the VHA opinion and afforded opportunity to respond. She has not identified any available pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis The Board notes it has reviewed all of the evidence in the Veteran's claims file and in "Virtual VA" (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. To establish service connection for the cause of a Veteran's death, it must be shown that a service-connected disability caused the death, or substantially or materially contributed to cause death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. The death of a Veteran will be considered as having been due to a service-connected disability when such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). A service-connected disability will be considered the principal (primary) cause of death when such disability, either singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A service-connected disability will be considered a contributory cause of death when it combined to cause death, or aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1). Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a claimed disability, there must be evidence of a present disability; evidence of an in-service incurrence or aggravation of a disease or injury; and evidence of a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Certain chronic diseases (including malignant tumors) may be service-connected on a presumptive basis if manifested to a compensable degree in a specific period of time postservice (one year for malignant tumors). 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, are presumed to have been exposed to an herbicide agent therein, unless there is affirmative evidence of non-exposure. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307. If a Veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease manifested to a degree of 10 percent or more the Veteran is entitled to a presumption of service connection for such disease even though there is no record of such disease during service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307, 3.309(e). [Pancreatic cancer, (with liver metastases), and pulmonary emboli are not among the enumerated diseases associated with herbicide exposure.] There is no specific statutory or regulatory guidance regarding the processing of asbestos-related claims, nor has the Secretary promulgated any regulations in regard to such claims. However, the VA Adjudication Procedure Manual, M21-1MR, Part IV, Subpart ii, Chapter 2, Section C (Manual)(amended December 13, 2005), provides information regarding processing of claims for service connection for disabilities resulting from asbestos exposure. The Court has held that VA must analyze an appellant's claim for service connection for asbestosis or asbestos-related disabilities under the appropriate administrative guidelines. Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). The Manual defines asbestos as a fibrous form of silicate mineral of varied chemical composition and physical configuration, derived from serpentine and amphibole ore bodies. M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Subsection (a). Common materials that may contain asbestos are steam pipes for heating units and boilers, ceiling tiles, roofing shingles, wallboard, fire-proofing materials, and thermal insulation. Id. at Subsection (a). Some of the major occupations involving exposure to asbestos include mining, milling, shipyard work, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products (such as clutch facings and brake linings), and manufacture and installation of products such as roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. Id. at Subsection (f). Asbestos fiber masses have a tendency to break easily into tiny dust particles that can float in the air, stick to clothes, and may be inhaled or swallowed. Id. at Subsection (b). Inhalation of asbestos fibers can produce fibrosis (the most commonly occurring of which is interstitial pulmonary fibrosis, or asbestosis), tumors, pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, and cancers of the lung, bronchus, gastrointestinal tract, larynx, pharynx, and urogenital system (except the prostate). Id. at Subsection (b). The latent period for the development of disease due to exposure to asbestos ranges from 10 to 45 or more years (between first exposure and the development of disease). Id. at Subsection (d). The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether or not: (1) service records demonstrate the Veteran was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether or not the Veteran was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. Id. at Subsection (h). The United States Court of Appeals for the Federal Circuit has held that when a claimed disorder is not included as a presumptive disorder direct service connection may nonetheless be established by evidence demonstrating that the disease was in fact "incurred" during service. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The appellant contends that the disabilities that caused the Veteran's death were due to his exposure to herbicides or Agent Orange while serving in Vietnam. The record shows that the Veteran served in Vietnam from July 1968 to March 1969; his exposure to herbicides in service is presumed. The Veteran's death certificate shows that the cause of his death was pancreatic cancer with liver metastases due to or a consequence of bilateral pulmonary emboli. The Board interprets this listing as indicating that pulmonary blood clots were the immediate cause of death, with the cancers as underlying causes. A history of alcohol was listed as a significant condition contributing to death but not resulting in the underlying cause. The Veteran had not established service connection for any disability during his lifetime. The Veteran's STR's are silent for complaints, findings, treatment, or diagnosis relating to pancreatic cancer, liver cancer (liver metastases) and/or pulmonary emboli. No pertinent abnormalities were noted on his service separation examination. In support of her claim that the Veteran's death-causing cancers are related to his exposure to herbicides in service that appellant notes that his first diagnosis of any cancer was 5 years after his discharge from active military service (apparently proposing that the appearance of yet another cancer , and so soon after service, points to herbicides as an etiological factor for the death-causing cancers). She relates that he had testicular cancer diagnosed in 1977, with treatment including removal of a testicle and radiation. An April 2007 private history and physical examination report on the Veteran's admission to a hospital shows a past surgical history of a right testicle orchiectomy. At that time he had assessments of bilateral pulmonary emboli and right lower extremity deep venous thrombosis, pancreatitis, and gastroesophageal reflux disease (GERD). Ultrasound of his legs showed an acute thrombus involving the right popliteal and right greater saphenous veins. Chest X-rays showed numerous bilateral pulmonary emboli. A May 2007 cancer center outpatient clinic report shows the Veteran had a diagnosis of duodenal cancer. Findings included a large, irregular, friable ulcer in the second portion of the duodenum. A sphincterotomy was done. A lower extremity Doppler revealed acute thrombus in the right popliteal vein and right great saphenous vein. Chest CT [computed tomography] revealed numerous bilateral pulmonary emboli. CT of the abdomen showed multiple areas of decreased attenuation in the liver. MRI [magnetic resonance imaging] of the liver showed multiple enhancing irregular lesions in the liver. There was also an ill-defined soft tissue intensity in the region of the pancreatic head. Biopsy showed invasive adenocarcinoma. Colonoscopy revealed two polyps, which were removed. In a subsequent May 2007 outpatient report, a private physician noted that the "adeno" was pancreatic and not ampullary. The liver lesions were most likely metastases. At the October 2011 hearing, the appellant testified that the Veteran did not have lung cancer diagnosed, but had upper respiratory infections. She related that he had other diseases that were caused by Agent Orange and caused or contributed to his death; had testicular and duodenal cancer; and had pancreatitis diagnosed three years prior to the diagnosis of his pancreatic cancer. R.S. testified at the hearing that one of the Veteran's last X-rays had a questionable lower lobe infiltrate. It was a bad X-ray, but another one was not performed because the Veteran was already dying of pancreatic cancer. His entire liver was metastasized. R.S. stated that the Veteran had elevated glucose blood work, which suggested diabetes, but that diabetes was never diagnosed, and also had hypertension (with a heart attack in 2004). R.S. further testified that the Veteran was exposed to chemicals during training in service. He related that during service the Veteran was involved in fighting a large fire or about four days without the use of any respiratory equipment. He stated that he did not know the nature of all the chemicals to which the Veteran was exposed to at that time. He stated that the Veteran served in areas with extremely high dioxin use (7 miles from the Cambodian border). In a June 2012 medical advisory opinion, based on review of the claims file, a VA medical provider noted that the Veteran's exposure to Agent Orange exposure is conceded but that none of the diseases listed as causing or contributing to his death is established to be related to Agent Orange/herbicide exposure. He did have disorders related to Agent Orange exposure (type 2 diabetes, and coronary artery disease), but these did not cause or contribute to his death. The consulting provider opined that it was unlikely that the Veteran's death was related to Agent Orange exposure in service. As it was also alleged (and the record raises such theory of entitlement) that the Veteran had disabilities listed as Agent Orange-related, which warranted service-connection, and which contributed to his death, the Board sought a VHA medical advisory opinion in the matter. Specifically, the VHA expert was asked to provide an opinion as to whether it is at least as likely as not (a 50 % or better probability) that diabetes mellitus and/or coronary artery disease (ischemic heart disease), which were shown or suggested, contributed to cause the Veteran's death; i.e., had debilitating effects or caused general impairment of health to the extent that they rendered him materially less capable of resisting the effects of the death-causing cancer and pulmonary emboli. The expert was also asked to describe the disability picture (symptoms, their severity, and associated impairment of function), as shown by the record, presented by the Veteran's diabetes (and any complications) and his coronary artery disease. In the June 2013 opinion in response, an Assistant Professor of Internal Medicine at the Iowa City VA Health Care System (Dr. K.G.) opined that it was less likely than not (less than a 50% probability) that the Veteran's diabetes and/or ischemic heart disease contributed to his death; or rendered him materially less capable of resisting the effects of the death-causing cancers and/or pulmonary emboli. The explanation of rationale included: Pancreatic carcinoma metastasized to the liver into the common duct bile duct and ampulla with duodenal involvement; this was all pancreatic adenocarcinoma and not separate cancers as was claimed. He noted that there was no evidence in the record of a nexus between any dioxin/Agent Orange, or asbestos exposure and pancreatic carcinoma. The expert further noted that type 2 diabetes was never formally diagnosed and the mild elevations of blood sugar found prior to his death were likely due to pancreatic carcinoma and/or previously diagnosed pancreatitis (and in any case did not meet the medical standards for a diagnosis of type 2 diabetes). Elevations in blood sugar were mild and there was no indication in the Veteran's medical records, nor was there reason to suspect, that the mild elevations in blood sugar had wide systemic debilitating effects. The period during which the Veteran had mild elevations in blood sugar was of short duration and probably related to the pancreatic cancer and/or previously diagnosed pancreatitis. Such could not have rendered him materially less capable of resisting the effects of death-causing cancer or the pulmonary emboli. The condition less likely than not (less than a 50% probability) contributed to the Veteran's death. The expert also noted that testicular cancer (status post right orchiectomy and radiation) was diagnosed in 1978, and it was very unlikely that it contributed in any way to cause the Veteran's death (and testicular cancer was not related to any of the Veteran's previous [environmental] exposures in service). Regarding hypertension with left bundle-branch block, left bundle-branch block was first diagnosed March 18, 2002 with no evidence of left bundle-branch block on prior (June 28, 1990) EKG. The Veteran's blood pressure was 120/92 on July 12, 1996, 138/88 on June 28, 1990, and 152/95 on March 18, 2002. The expert observed that without further diagnostic testing this could be related to ischemic artery disease which may be related to previous Agent Orange exposure. However, on review of the records, there was no indication of significant ischemic artery disease by symptoms or by other records. Therefore, it did not, in any way contribute significantly to the cause of the Veteran's death; nor did it render him materially less capable of resisting the effects of death-causing cancer or the pulmonary emboli, and less likely than not (less than a 50% probability) contributed to the Veteran's death. The Veteran's death-causing disease (pancreatic cancer with liver metastases) was not manifested during service or in the first postservice year. Consequently, service connection for such on the basis that it became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C.A. § 1112) is not warranted.. Notably, pancreatic cancer, liver metastases, and pulmonary emboli are not listed in 38 C.F.R. § 3.309(e)(as diseases associated with exposure to herbicides). Hence, although the Veteran served in Vietnam (and is presumed to have been exposed to Agent Orange), this matter does not fall within the purview of 38 U.S.C.A. § 1116. Consequently, to establish service connection for the cause or the Veteran's on the theory that his death-causing diseases were related to his exposure to herbicides, the appellant must affirmatively show such a nexus. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board notes that the appellant has alleged that the Veteran had a heart attack in 2004. Evidence of a heart attack invokes the presumptive provisions of 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309 (e) (for ischemic heart disease). However, heart disease is shown as causing or contributing to the Veteran's death on his death certificate or in any medical evidence of record). The competent (medical) evidence that directly addresses the matter of a nexus between the Veteran's death-causing diseases and his service, is in the June 2012 opinion (based on a review of the record) by a VA medical provider, who opined that none of the diseases listed as causing or contributing to the Veteran's death is caused by Agent Orange. The diseases (associated with the Veteran during his lifetime) that were listed in various post-service medical records included pancreatic cancer (adenocarcinoma) with metastases to the liver, testicular cancer, diabetes, coronary artery disease, asthma, hypertension, hypercholesterolemia, deep vein thrombosis, pulmonary emboli, pancreatitis, duodenal cancer, phlebitis, and GERD. With the exception of type 2 diabetes and coronary artery disease, none of the other diseases is listed in 38 C.F.R. § 3.309(e) (as a disease associated with exposure to certain herbicides. And while type 2 diabetes, and coronary artery disease are related to Agent Orange exposure, neither is listed on the Veteran's death certificate. As type 2 diabetes, and coronary artery disease (ischemic heart disease), are considered related to Agent Orange exposure, the Board considered whether such diseases contributed to cause the Veteran's death. Because the question of whether an insidious process such as coronary artery disease or diabetes has debilitating effects or causes impairment of health in a specific circumstances is a medical question (and because these diseases affect vital organs, requiring such consideration; see 38 C.F.R. § 3.312), the Board sought a medical advisory opinion in the matter. The VHA expert, a professor of internal medicine, reviewed the Veteran's records and opined that he did not believe that diabetes mellitus or coronary artery disease could have rendered the Veteran materially less capable of resisting the effects of death-causing cancer or the pulmonary emboli, or contributed to the Veteran's death. He explained that the Veteran never had type 2 diabetes formally diagnosed. And, while the evidence shows he experienced mild elevations of blood sugar, that was likely due to the pancreatic carcinoma and/or previously diagnosed pancreatitis, and did not meet the medical standard for type 2 diabetes. Thus, any diabetes was not a significant factor. Further, while the Veteran could have had ischemic artery disease (which the Board finds reasonable to concede based on the opinion) there was no indication of significant ischemic artery disease by symptoms or by other records. He opined that therefore, in no way did ischemic artery disease contribute significantly to cause the Veteran's death, or render him materially less capable of resisting the effects of the death-causing cancer and pulmonary emboli. The Board finds the opinions offered by the VHA expert to be very probative, and persuasive, evidence. They reflect familiarity with the entire record; address all questions posed (with apparent concessions of certain facts such as the presence of ischemic heart disease in the appellant's favor) ); and include rationale with citation to supporting factual data. There is no competent (medical) evidence to the contrary. The appellant alternatively contends that the Veteran was exposed to asbestos during his military service, and that such exposure contributed to cause his death. As was noted, the Veteran's various ailments and diseases included pancreatic cancer (adenocarcinoma) with metastases to the liver, testicular cancer, diabetes, coronary artery disease, asthma, hypertension, hypercholesterolemia, deep vein thrombosis, pulmonary emboli, pancreatitis, duodenal cancer, phlebitis, and gastroesophageal reflux disease. Service personnel records show that he served in the Navy and that his military occupational specialty was construction mechanic. A memorandum of exposure to asbestos dated in March 2012 shows, that as a construction mechanic in the Navy, the Veteran had a minimal probability of exposure to asbestos. Based on this development, the Board finds that some (albeit not substantial) exposure to asbestos may be conceded. To prevail under this alternative theory of entitlement, the evidence must establish that the Veteran had an asbestos-related disease, and that such disease caused or contributed to cause his death. June 2012 VA consulting physician opined that it was extremely unlikely that the Veteran's death was related to asbestos exposure in the military. He noted that asbestos causes mesothelioma, interstitial lung disease, pleural plaques, pleural effusion, round atelectasis and primary lung cancer. The Veteran had none of those diseases or disorders. He further noted that asbestos does not cause pancreatic cancer, liver cancer, or pulmonary emboli; therefore, it is unlikely that the Veteran's death was related to asbestos exposure during service. The VHA expert also found no evidence that asbestos exposure caused pancreatic carcinoma. In summary, the probative evidence does not support that the listed causes of the Veteran's death were in any way related to his service, or that any disease he had that could be related to his service and any environmental exposures therein (diabetes and ischemic heart disease included) contributed to cause his death. The Board has no doubt that the appellant is sincere in her belief that the disabilities that caused or contributed to the Veteran's death were related to his period of service, to include exposure to Agent Orange and asbestos in service. The Board has considered her testimony, and that of R.S.. Regarding the hearing testimony to the effect that the Veteran had a questionable lower lobe infiltrate and was involved in fighting fires in service (with unknown related environmental exposures), these are mere speculations on the part of the person testifying (R.S.), and are not probative evidence to establish either that the Veteran had lung cancer which contributed to his death or that any additional unidentified environmental exposure cause a lung disability that contributed to the Veteran's death. Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a). However, the medical questions presented in this case, regarding the etiologies of death causing diseases and the disabling effects of insidious processes are medical questions beyond the capabilities of lay observation. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). Notably, the appellant does not cite to any medical opinions or medical literature that support her proposed theories of entitlement. As the diseases which caused or contributed to cause the Veteran's death are not shown to have been related to his service, including as due to exposure to Agent Orange or asbestos, and he is not shown to have had any disability which warranted service connection and is shown to have contributed to his death, the preponderance of the evidence is against the appellant's claim of service connection for the cause of the Veteran's death. Accordingly, her appeal in this matter must be denied. ORDER The appeal seeking service connection for the cause of the Veteran's death is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs