Citation Nr: 1329764 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 11-30 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for bladder cancer, to include as due to exposure to herbicides. 2. Entitlement to service connection for renal cell carcinoma, to include as due to exposure to herbicides. 3. Entitlement to service connection for pancreatic cancer, to include as due to exposure to herbicides. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M.W. Kreindler, Counsel INTRODUCTION The Veteran served on active duty from July 1970 to January 1972. These matters came to the Board of Veterans' Appeals (Board) from a June 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were remanded in September 2012. In support of the Veteran's appeal, the Veteran's representative submitted a January 2012 VA examination pertaining to a different Veteran and a copy of a February 2013 Board decision pertaining to a different Veteran. As such evidence is not relevant and material to the Veteran's case, a waiver is not necessary. See 38 C.F.R. §§ 19.31, 20.1304(c) (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. Bladder cancer was not manifested during service, was not manifested within a year of separation from service, and bladder cancer is not otherwise related to the Veteran's active service, to include exposure to herbicides. 2. Renal cell carcinoma was not manifested during service, was not manifested within a year of separation from service, and renal cell carcinoma is not otherwise related to the Veteran's active service, to include exposure to herbicides. 3. Pancreatic cancer was not manifested during service, was not manifested within a year of separation from service, and pancreatic cancer is not otherwise related to the Veteran's active service, to include exposure to herbicides. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for bladder cancer have not been met. 38 U.S.C.A. §§ 1110, 1116, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. The criteria for an award of service connection for renal cell carcinoma have not been met. 38 U.S.C.A. §§ 1110, 1116, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 3. The criteria for an award of service connection for pancreatic cancer have not been met. 38 U.S.C.A. §§ 1110, 1116, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice from VA must inform the claimant 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 claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (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. Id. at 486. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in February and May 2010 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. Such letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, to include substantial compliance with the September 2012 Board Remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The evidence of record contains the Veteran's service treatment records, records from Sibley Memorial Hospital, records and an October 2009 statement from John L. Losee, M.D., a July 2011 statement from Gregory Sibley, M.D., and a statement from Mark Schoenberg, M.D. In September 2012, VA requested that the Veteran complete a VA Form 21-4142, Authorization and Consent to Release Information, pertaining to Dr. Sibley, Dr. Losee, and Dr. Schoenberg. The Veteran did not respond to such request; however, the relevant records were received as detailed hereinabove. Thus, the Board has determined that there has been proper compliance with 38 C.F.R. § 3.159(c)(1). The Board otherwise concludes that no available outstanding evidence has been identified pertaining to the claims. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the claims. In October 2012, a VA opinion was proffered and in May 2013 a VA opinion was proffered per a Veterans Health Administration (VHA) request. The opinions will be discussed in detail below. McLendon v. Nicholson, 20 Vet. App. 79 (2006). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Criteria & Analysis Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368- 69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it pertains to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). Certain chronic diseases, such as malignant tumors, are presumed to have been incurred in service if manifested to a compensable degree within one year of discharge from service; or if manifested in service and at any time thereafter. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For purposes of establishing service connection for a disability resulting from exposure to a herbicide agent, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, 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 service. 38 U.S.C.A. § 1116(f). The evidence of record reflects that the Veteran had active service in the Republic of Vietnam during the applicable period, thus it is presumed that he was exposed to herbicides during active service. It is provided that the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.308(a)(6)(ii). These diseases include chloracne or other acneform disease consistent with chloracne, type II diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, Non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, Parkinson' disease, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), AL amyloidosis, and soft-tissue sarcoma. 38 C.F.R. § 3.309(e); see Notice, 75 Fed. Reg. 168, 53202-16 (Aug. 31, 2010). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 67 Fed. Reg. 42,600 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-32,407 (Jun. 12, 2007); see also Notice, 74 Fed. Reg. 21,258-21260 (May 7, 2009); see also Notice, 75 Fed. Reg. 32540 (June 8, 2010); see also Notice, 77 Fed. Reg. 47924-28 (August 10, 2012). The Secretary has specifically determined that there is no positive association between exposure to herbicides and the development of bladder cancer, renal cancer, and pancreatic cancer. See Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47924-28 (August 10, 2012), and Disease Not Associated With Exposure to Certain Herbicide Agents, 67 Fed. Reg. 42,600 (June 24, 2002). In making this determination, the Secretary relied on reports received from the National Academy of Sciences, as well as all other sound medical and scientific information and analyses available. Id.; see also 38 U.S.C.A. § 1116(b)(2). There is no other medical evidence of record to rebut the conclusion that there is no positive association between exposure to Agent Orange and the development of bladder cancer, renal cancer, and pancreatic cancer. Thus, despite the Veteran's presumed exposure to an herbicide agent, presumptive service connection under 38 C.F.R. § 3.307(a)(6) is not for application as he does not have a presumptive disability. For these reasons, the Board finds that the presumptive regulations regarding exposure to Agent Orange are not applicable in this case. See 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). Thus, presumptive service connection for bladder cancer, renal cell carcinoma, and pancreatic cancer due to Agent Orange exposure is not warranted. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309. Notwithstanding the foregoing, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The rationale employed in Combee also applies to claims based on exposure to Agent Orange. Brock v. Brown, 10 Vet. App. 155 (1997). Where the Board is presented with conflicting medical evidence, it is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). In this regard, the Board notes that the Federal Circuit and the Court have both specifically rejected the "treating physician rule." See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Guerrieri v. Brown, 4 Vet. App. 467 (1993). Instead, the Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994); see also Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (it is not error for the Board to favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. Service treatment records are negative for complaints of or diagnoses of bladder cancer, renal cell carcinoma, and pancreatic cancer, and the post-service medical evidence reflects that bladder cancer was diagnosed in or about 2004 or 2005, and renal cell and pancreatic cancers were diagnosed in 2009. This constitutes a period of over 30 years between service separation and diagnoses. In this regard, evidence of a prolonged period without medical complaint can be considered as a factor, along with other factors concerning the Veteran's health and medical treatment during and after military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Correspondence dated in September 2010 from Dr. Schoenberg states that the Veteran is undergoing treatment for invasive bladder cancer and that there is ample clinical and experimental evidence to suggest a link between the development of bladder cancer and exposure to solvents and pesticides. Dr. Schoenberg stated his belief that exposure to Agent Orange could cause bladder cancer in Vietnam Veterans and that coverage of medical care delivered in the course of managing malignancy of the bladder should be considered for coverage by VA. Correspondence dated in July 2011 from Dr. Sibley states that the Veteran has undergone treatment for three unrelated malignancies over the past few years which include neuroendocrine cancer of the pancreas (surgically removed), cancer in the right kidney (surgically removed), and invasive bladder cancer that has been treated aggressively with chemotherapy and radiation therapy. Dr. Sibley stated that this raises a concern for some external carcinogenic agent. The Veteran denied a history of prior radiation exposure, prior chemotherapeutic agents, and significant exposure to known carcinogens other than a light smoking history. There is one important exception, however, which is his significant Agent Orange exposure while serving a tour of duty in Vietnam. It is for that reason that he has put in a claim to VA for just compensation. Dr. Sibley recommended expedited review based on his aggressive and fast-moving carcinoma. In October 2012, the Veteran underwent a VA examination. The VA examiner noted that Dr. Sibley did not opine as to whether herbicide exposure is the likely cause of the Veteran's cancer, but rather recommended expedited review due to the aggressive nature of bladder cancer. The examiner noted that the Veteran appeared to have a good response to chemotherapy and radiation therapy completed 17 months prior, with report of a CT/abd/pelvis in January 2012 showing no evidence of residual malignancy. The examiner noted the Veteran's report that his father died at age 58 from metastatic colon cancer. His oldest daughter has a history of a sarcoma, resected from her leg approximately 30 years prior, and his remaining three daughters are well. The VA examiner opined that the Veteran's conditions are less likely than not due to service. He acknowledged Dr. Schoenberg's suggestion that Agent Orange could cause bladder cancer, but rejected this as specific evidence was not provided and because that doctor's opinion merely suggested a connection between bladder cancer in Vietnam Veterans in general, without citing to anything particularly suspicious in the facts surrounding the Veteran's particular case. The VA examiner then reiterated VA's position that a positive association exists for twelve conditions, which do not include bladder cancer, nor pancreatic neuroendocrine tumors, nor renal cell cancer. The VA examiner stated that while it was not possible for her to identify the etiology of the Veteran's malignancies, it was possible to identify known risk factors. She then explained that bladder cancer is the most common of the 3 malignancies in his history and is most strongly associated with cigarette smoking, which was acknowledged by the patient. Renal cell carcinoma is also associated with cigarette smoking as well as hypertension (also noted by history). Pancreatic neuroendocrine tumors are primarily sporadic, without clear etiologic factors, though they may be associated with hereditary conditions, including von Hippel Lindau syndrome in which patients may have renal cell cancer - particularly clear cell tumors, as in this Veteran's case, in association with pancreatic neuroendocrine cancer. She observed that the Veteran had not been considered or tested for von Hippel Lindau syndrome, and that she would raise this with Dr. Schoenberg. There was no family history of renal cell cancer, but there was a strong family history of cancer, with the Veteran's father dying at an early age of colon cancer and his daughter having a sarcoma diagnosis at a young age. As the examiner noted "(t)his also raises concern for an inherited susceptibility accounting for the multiple malignancies. Given the lack of known association between the Veteran's malignancies and Agent Orange, and the multiplicity of malignancies, it seems that a germ-line (inherited) rather than somatic mutation may account for this presentation." As detailed, while Dr. Sibley indicated a concern for some external carcinogenic agent in light of his cancer diagnoses, he did not specifically provide an etiological opinion, but rather it was recommended expedited review based on his aggressive and fast-moving carcinoma. The VA examiner agreed that Dr. Sibley did not provide an etiological opinion. Thus, the statement from Dr. Sibley cannot provide a bases for service connection. As alluded to by the VA examiner, the letter from Dr. Schoenberg is also not sufficient to enable a grant of service connection because it is not based on specific facts unique to the Veteran's case. However, it does at least suggest the possibility that the currently diagnosed malignancies may be related to service, to include herbicide exposure therein. The VA examiner's negative opinion, while accompanied by a rationale, is also deemed to be incomplete. For example, while the examiner at one point appeared to believe that the Veteran's malignancies were of hereditary origin, she later appeared less certain, suggesting that testing be accomplished to further determine the etiology of the pancreatic cancer, which may be associated with hereditary conditions such as von Hippel Lindau syndrome. Overall, a full reading of the October 2012 opinion ultimately leads the Board to find it largely speculative in nature. Both Federal regulation and case law preclude granting service connection predicated on a result of speculation or mere possibility. 38 C.F.R. § 3.102; see Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (evidence favorable to the veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection); see Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); see also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative). Thus, neither opinion can provide the bases for service connection but in light of such opinions in March 2013 the Board requested through the VHA that a physician address the etiology of his claimed conditions. In May 2013, a VA hematologist/oncologist reviewed the Veteran's claims folder, which included the Veteran's medical records and the opinions discussed hereinabove. The examiner acknowledged a diagnosis of superficial bladder cancer in 2004-2005, and diagnoses of renal cell carcinoma in September 2009, and neuroendocrine tumor of the pancreas in 2009. In 2011, he was found to have invasive transitional cell carcinoma of the bladder and underwent neoadjuvant chemotherapy with ciplatin plus gemcitabine times 4 cycles followed by radiation therapy and achieved a remission. The examiner also acknowledged the Veteran's family history being significant for early colorectal cancer in his father who died at age 58 and a daughter who has a history of sarcoma. The examiner explained that there are a number of known risk factors for the development of bladder cancer. These include personal smoking history (two times more likely than non-smokers for former smokers and 4 times more likely than non-smokers for active smokers, Caucasian race/ethnicity (two times more likely than other races/ethnicities), male gender, chronic bladder irritation or infections, bladder birth defects, prior exposure to chemotherapy or radiation therapy, schistosomiasis, genetics or family history of syndromes such as Cowden disease or Lynch syndrome or a mutation of the retinoblastoma gene, or environmental exposures to petrochemicals including arotmatic amines - benzidine and betanapthylamine used in the dye industry or organic chemicals used in the rubber, leather, and textile industries. Other workers at increased risk include painters, machinists, printers, hairdressers and truck drivers (exposure to diesel fumes). A link between chemical/environmental exposures and concurrent smoking has been identified. The examiner noted that the National Academy of Science 2010 Veterans and Agent Orange Update was reviewed. This report specifically addresses the potential mechanism, animal studies and reported incidence in various populations who have had exposures either during their military service, employment at a chemical production facility, other environmental exposure (accidental known exposure), or in the agricultural or forestry fields resulting in bladder cancer. The examiner stated that at this time there appears to be insufficient evidence to determine a direct association between exposure to the chemicals of interest and bladder cancer. This finding holds true for persons with documented evidence of clinical exposure based on obtained levels as well as assumed exposure based on geographic proximity to known potential chemical exposures. The only reported cohort with 95 percent confidence intervals suggesting a possible significant increased risk for bladder cancer were the NIOSH Mortality Cohort looking at 12 US plants that produced dioxin and phenoxy herbicides from 1942 to 1984 which included a sub-set who also had exposure to 4-aminobiphenyl which is a known bladder carcinogen. Renal cell carcinoma (clear cell histology) has been demonstrated in higher prevalence in males, individuals who are tobacco users, hypertensives, obese individuals, or persons with various familial syndromes. Known environmental exposure to cadmium, asbestos and petroleum by-products have also been linked to renal cell carcinoma. The 2010 Veterans and Agent Orange Update was reviewed and again did not demonstrate a clear link between either military or civilian individuals exposed to Agent Orange or its chemical components and renal carcinoma. The examiner was unable to locate a review of Agent Orange exposure or herbicide exposure and development of pancreatic neuroendocrine tumors in the 2010 Veterans Agent Orange Update or in other published sources. This is most likely due to the rare occurrence of these tumors and often incidental finding of such as the most common sub-type is a non-functional (non-hormone secreting) pancreatics neuroendocrine tumor. Inherited disorders such as multiple endocrine neoplasia-type 1 (MEN-1), von Hippel-Lindau disease, neurofibromatosis 1, and tuberous sclerosis have been linked to increased incidence of pancreatic neuroendocrine tumors. There is no record suggesting that the Veteran has had any genetic testing done to date to evaluate for these causes. No clinical findings recorded support diagnoses of MEN-1, tuberous sclerosis or neurofibromatosis. His family history does not clearly support an inherited syndrome, either. The examiner noted concern that he may have von Hippel-Lindau disease which is a heritable multi-system cancer syndrome associated with a germline mutation of the VHL tumor suppressor gene located on chromosome 3. The most common tumors associated with this syndrome include vascular tumors of the central nervous system and retina, clear cell renal carcinomas, pheochromocytomas, pancreatic islet cell (neuroendocrine) tumors, endolymphatic sac tumors, and benign cysts affecting a variety of organs. In a single-center retrospective analysis, roughly 17 percent of patients identified with von Hippel-Lindau disease were noted to have pancreatic neuroendocrine tumors. With regards to the Veteran's case, like nearly all cases of malignancy, it is very difficult and almost impossible to determine the exact etiology or precipitating event that led to the development of cancer, unless there appears to be a very clear genetic pre-disposition or known environmental risk factor (such as 90 percent of lung cancer is a result of smoking). He does not carry any of the 12 medical conditions that have been clearly validated in causation in relation to Agent Orange exposure. The examiner noted agreement with the prior VA examiner that in his case he is more likely to have a germ-line mutation (possibly von Hippel-Lindau disease) that is the result in the formation of these multiple malignancies rather than the result of a somatic mutation from an environmental herbicide exposure particularly since none of his malignancies seem to have higher incidence in individuals with known high level herbicide exposure. From the available medical records, the examiner is inclined to believe that his greatest risk factor for developing malignancy was his former tobacco use, and that unless ruled out by genetic evaluation, he may harbor a genetic predisposition to tumor development (such as von Hippel-Lindau disease). With this information, coupled with review of the National Academy of Science 2010 update on Veterans and Agent Orange, the examiner is inclined to believe that it is unlikely or less likely that his bladder cancer, renal cell cancer, and pancreatic neuroendocrine cancer were caused by or aggravated by herbicide exposure in Vietnam. Based on the record and the May 2013 VHA examiner's opinion, the Board must conclude that a preponderance of the evidence is against a finding that the Veteran's bladder, renal cell, and pancreatic cancers manifested during service or that they are otherwise related to his active service. The Board accepts the May 2013 VHA opinion as being the most probative medical evidence on the subject, as it contains detailed rationale for the medical conclusions and is based on sound medical principles. See Boggs v. West, 11 Vet. App. 334 (1998). As detailed by the examiner, his tobacco use constituted his greatest risk factor for developing malignancy and a genetic predisposition could also be a contributing factor. Based on a review of the claims folder and relevant research materials, the examiner concluded that his bladder cancer, renal cell carcinoma, and pancreatic cancer were not caused by herbicide exposure. The Board acknowledges the submitted VA examination report pertaining to a different Veteran which relates renal cancer to herbicide exposure in service, and a February 2013 Board decision pertaining to a different Veteran which determined that service connection for renal cell carcinoma was warranted based on a relationship to herbicide exposure in service. Such submissions, however, do not constitute competent evidence in support of the current issues before the Board. Such opinion and decision do not contemplate the particular facts surrounding the Veteran's bladder cancer, renal cell carcinoma, and pancreatic cancer case. Thus, such opinion and examination cannot provide the bases for service connection. As detailed, a VHA examiner reviewed the particulars of the Veteran's case and provided a negative etiological opinion. The Board has considered the Veteran's contention that a relationship exists between his bladder cancer, renal cell carcinoma, and pancreatic cancer and his service, to include his belief that these disabilities are due to exposure to herbicides in service. The Veteran, however, is not competent to offer an opinion as to the etiology of his bladder cancer, renal cell carcinoma, and pancreatic cancer as he does not have the requisite medical expertise. Indeed, a veteran's ability to render n opinion of etiology is limited to observable, immediate cause-and-effect relationships, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As the Veteran's bladder cancer, renal cell carcinoma, and pancreatic cancer were not shown in service, and the most probative evidence does not indicate a causal link between his bladder cancer, renal cell carcinoma, and pancreatic cancer and active service, to include herbicide exposure, the Board finds that the preponderance of the evidence is against the Veteran's claims of service connection. In sum, the Board is compelled to conclude that the preponderance of the evidence is against the Veteran's claims of service connection for bladder cancer, renal cell carcinoma, and pancreatic cancer. It follows that the Board is unable to find such a state of approximate balance of the positive evidence to otherwise warrant a favorable decision. 38 U.S.C.A. § 5107(b). CONTINUED ON NEXT PAGE... ORDER Entitlement to service connection for bladder cancer is denied. Entitlement to service connection for renal cell carcinoma is denied. Entitlement to service connection for pancreatic cancer is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs