Citation Nr: 1330174 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 10-41 906 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for the Veteran's cause of death. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The late Veteran served on active duty from November 1950 to September 1954. The appellant in the present claim is his surviving widow. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the appellant's claim of entitlement to service connection for the Veteran's cause of death. FINDINGS OF FACT 1. The Veteran died in May 2009 as a result gastric carcinoma, with chronic obstructive pulmonary disease listed as a significant condition contributing to his death but not resulting in the immediate cause of his death. 2. At the time of his death, the Veteran was service-connected for residuals of a right ankle fracture (rated 20 percent disabling) and a duodenal ulcer (rated 10 percent disabling), which produced a combined rating of 30 percent. 3. The Veteran's service-connected duodenal ulcer did not cause, nor did it substantially or materially contribute to his death. 4. The Veteran's terminal gastric carcinoma began many years after service, was not the result of service or any incident of service, and was not shown to be secondary to, or otherwise permanently worsened beyond its natural progression by the Veteran's service-connected duodenal ulcer. 5. The clinical evidence of record does not indicate that the Veteran died of a service-connected disability or died while having a disability evaluated as total and permanent in nature resulting from a service-connected disability. CONCLUSION OF LAW A disability incurred in or aggravated by service did not cause or contribute to the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1310 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a), (b) 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) and the duties to notify/assist. With respect to the appellant's claims for the Veteran's cause of death, the Board notes that in accordance with the VCAA, VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his/her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA 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; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his/her possession that pertains to the claim. Additionally, in the subsequent case of Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006), the Court held that adequate notice must also include informing the claimant of (4) degree of disability; and (5) effective date. Furthermore, in the context of a claim for service connection for cause of death benefits, statutory notice must include: (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a cause of death claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a cause of death claim based on a condition not yet service connected (predicated on the contentions or theory of service connection advanced by the veteran's survivor). 38 U.S.C.A. § 5103(a). See Hupp v. Nicholson, 21 Vet. App. 342 (2007). The appellant's claim for VA compensation for service connection for the Veteran's cause of death was received by VA in mid-May 2009. In response, she was furnished with a Dingess-compliant notice letter issued in June 2009, prior to the RO's adjudication of the claim in July 2009, and a subsequent Hupp-compliant notice letter in June 2010. These letters, collectively, fully comply with the notice requirements. To the extent that a timing of notice defect exists in that fully compliant notice was not provided to the claimant prior to the adjudication of her claim in the first instance, the later notice was followed by subsequent readjudications, most recently in a September 2012 rating decision/supplemental statement of the case, thereby curing the defective notice error. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Furthermore, the record includes correspondence reflecting that the appellant's contentions and proactive actions that she undertook to develop her cause of death claim. She demonstrated that she had actual knowledge of the disabilities for which a Veteran was service connected at the time of his death (i.e., duodenal ulcer). She also knew that she needed to submit evidence that would establish a nexus between the Veteran's established cause of death (as listed in his death certificate) and his period of military service, either as directly or presumptively linked to such service or as secondarily related to, or aggravated by the Veteran's service-connected duodenal ulcer. Such has been the crux of her claim for service connection for cause of death. The duty to assist the appellant has also been satisfied. All relevant records that are obtainable have been associated with the Veteran's claims file and were reviewed by both the RO and the Board in connection with the claim. The late Veteran's service personnel and treatment records and his relevant post-service private and VA treatment records for the period from 1955 - 2009, and also his official death certificate listing those conditions which caused or contributed to his death in May 2009, have been obtained and associated with the evidence. The Board has also researched the late Veteran's claims file as it appears on the VBMS and Virtual VA electronic databases for any and all records relevant to the current claim. Clinical evidence addressing the likelihood of a relationship between the Veteran's military service and his gastric carcinoma was also obtained, which included medical records obtained during the course of developing the late Veteran's claim for service connection for gastric carcinoma that was filed during his lifetime, and which was adjudicated and denied in a March 2008 rating decision that was not timely challenged or appealed by the Veteran and which became final. (The Board notes at this juncture that there were no active claims filed by the late Veteran that were pending or otherwise in appellate status at the time of his death in May 2009.) This evidence includes statements from the late Veteran's private treating physician and a February 2008 VA clinician's opinion. Additionally, the Board has provided the Veteran's claims file containing the aforementioned medical evidence to a VA medical expert for review, after which nexus opinions addressing the likelihood that the Veteran's death was service-related were presented in a report dated in May 2013, with additional clarifying opinions presented at the Board's request in a June 2013 addendum to the aforementioned report. These opinions are predicated on a thorough review of the Veteran's pertinent clinical history and are supported by a detailed rationale. As such, the Board deems the May - June 2013 medical expert opinions to be adequate for VA adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In view of the foregoing discussion, the Board concludes that the appellant has had adequate opportunity to present evidence and argument in support of her claim for service connection for the Veteran's cause of death and that there has been sufficient development of the record to adjudicate the claim on the merits. A remand for further evidentiary development is therefore unnecessary. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for the Veteran's cause of death. The appellant is claiming entitlement to service connection for the cause of the Veteran's death. 38 U.S.C.A. § 1310. In a claim where service connection is established for a disability prior to the death of the veteran, the initial inquiry is to determine whether the service-connected disability was either the principal or contributory cause of the veteran's death. See 38 C.F.R. § 3.312. In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. See 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312(a). In order to constitute the principal cause of death the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. See 38 C.F.R. § 3.312(b). This question will be resolved by the use of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the Veteran. 38 C.F.R. § 3.312(a). For a service-connected disability to be considered the principal or primary cause of death, it must singly, or with some other condition, be the immediate or underlying cause, or be etiologically related thereto. 38 C.F.R. § 3.312(b). In determining whether a service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it 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). Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. 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). For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. Feb. 21, 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). Gastric carcinoma is such a listed disease. A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as malignant tumors (to include gastric carcinoma), are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability which is proximately due to, the result of, or otherwise aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a), (b). The evidence must show: (1) the existence of a disability at the time of the Veteran's death; (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, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). The Veteran's claims file shows that he died in May 2009 at age 78. His death certificate shows that his immediate cause of death was listed solely as "Gastric Carcinoma," whose approximate interval onset to death was described by the certifying physician as being only "months." COPD alone was identified as a significant condition contributing to death but not resulting in the underlying cause (i.e., gastric carcinoma). The clinician regarded the Veteran's manner of death as being natural and that use of tobacco probably contributed to his death. The death certificate does not attribute the fatal stomach cancer to have been due to, or a consequence of any other medical condition. At the time of his death, the Veteran was service connected only for residuals of a right ankle fracture (rated 20 percent disabling) and a duodenal ulcer (rated 10 percent disabling). Pursuant to 38 C.F.R. § 4.25, a combined 30 percent disability rating for these two service-connected disabilities was in effect since January 2007. The Veteran's service treatment records reflect treatment for an aching stomach, but no indication of stomach cancer during active duty. The Veteran was discharged from active duty in September 1954. Post-service medical records show treatment of the Veteran for epigastric complaints attributed to duodenitis. A VA gastrointestinal (GI) series in October 1955 revealed a normal esophagus and stomach, with the presence of some deformity of the duodenal cap that was deemed to be the apparent result of an old duodenal ulcer, but with no active ulcerative crater present in the duodenum. A physician certified that he diagnosed the Veteran with a duodenal ulcer after examination in December 1954. VA examination in October 1955 did not objectively indicate the presence of gastric carcinoma or any related cancerous or pre-cancerous findings affecting his gastrointestinal system. Based on the aforementioned clinical findings and evidence, the Veteran was granted service connection for a duodenal ulcer in a November 1955 rating decision. VA clinical notes dated in February 1964 and September 1967 show treatment of the Veteran for epigastric complaints attributed to his duodenal ulcer. Private medical records include the report of a biopsy of an excised duodenal polyp performed in January 2007, which did not reveal any cancerous lesions or findings indicative of cancer in the duodenum. A gastric biopsy was performed in April 2007, which is the earliest objective clinical evidence confirming the presence of gastric adenocarcinoma in the Veteran. Noteworthy is the objective determination of this examination report and subsequent examinations showing no evidence of the presence of the Helicobacter pylori bacteria in the Veteran's stomach and duodenum. The subsequent medical records associated with his treatment for gastric adenocarcinoma show that the cancer was metastasizing and progressively worsened. The report of a February 2008 VA examination shows that the Veteran's electronic and hardcopy claims files and pertinent medical history were reviewed by the examining clinician, including the related history of long-term tobacco and alcohol use (i.e., tobacco consumption at the rate of one pack per day since age 20; consumption of at least one ounce to up to one pint of whisky per day until his recent diagnosis of stomach cancer in 2007) and persistent epigastric pain since active duty as related to the examiner by the Veteran and his spouse. The VA clinician examined the Veteran and thereafter determined that the Veteran had a remote history of a duodenal ulcer and that his metastatic gastric adenocarcinoma was not likely related to his service-connected remote history of duodenal ulcer. The stated rationale for this opinion was that there was no objective clinical history of gastric adenocarcinoma prior to 2007, and that the Veteran had a long history of tobacco addiction at the rate of one pack per day since age 20 and abusive alcohol consumption of at least one ounce to up to one pint of whisky per day until recently. Although the Helicobacter pylori bacterium that causes ulcers is associated with adenocarcinoma of gastric origin, the Veteran had multiple negative tests for this bacteria, thereby indicating that he does not have an ulcer. Furthermore, the medical evidence does not demonstrate treatment for a chronic or recurrent gastric or ulcer condition since 1967 up until 2007. The Veteran reported that he treated his epigastric symptoms with over-the-counter nonprescription medications for many years, but the record was silent on any documentation of chronic or recurrent gastrointestinal problems. Therefore, the opining VA clinician concluded that the Veteran's development of adenocarcinoma was not etiologically related to his service-connected duodenal ulcer but rather to his history of tobacco and alcohol abuse in view of his negative Helicobacter pylori status or any documented treatment records for a chronic and/or recurrent stomach condition. In written correspondence dated in 2008 and 2009 from the Veteran's private physician, Larry L. Frase, M.D., reported that the Veteran was being followed for metastatic adenocarcinoma of the stomach with distant metastases to his lung and locoregional recurrent disease. At the time of his initial cancer diagnosis, he was noted to have "mucosal irregularities of [his] stomach [that were] consistent with gastric ulceration," and a "remote history of gastric ulcer." Dr. Frase noted that clinical studies have clearly demonstrated a common epidemiological risk factor association between gastric ulcer and gastric cancer and that although "[t]he association between these two entities is some what controversial[,]. . . it is reasonable to assume there may be some relation between the [Veteran]'s gastric cancer and his history of gastric ulcers. In May 2009, the Veteran succumbed to his gastric adenocarcinoma. In her self-reported capacity as a registered nurse, the appellant stated that the Veteran's fatal case of gastric adenocarcinoma had to have been associated in some manner to his service-connected duodenal ulcer as the location of this ulcer was proximate to the site of his terminal gastric cancer. In March 2013, the Board referred the case to a VA medical expert for a nexus opinion regarding the likelihood that the Veteran's fatal gastric cancer had its onset during service, or was etiologically related to, or aggravated by his service-connected duodenal ulcer, or that his service-connected duodenal ulcer had otherwise materially contributed to his death. In response, the VA medical expert presented the following opinions in May 2013 and June 2013, which collectively state, in pertinent part, as follows: On basis of analysis of the [Veteran's claims file], there is no firm evidence that the Veteran had an active ulcer [due to the non-conclusive findings obtained on clinical studies in 1954 - 55 and the absence of the Helicobacter pylori bacteria associated with active peptic ulcer disease on all tests conducted in 2007 - 2009], and even if he had, there is no evidence that [the] ulcer caused or aggravated [his] gastric cancer. It [is] not [at] least as likely as not (a 50% probability or greater) that the gastric carcinoma that caused the veteran's death had its onset in or was incurred in or aggravated (made worse) by active service or a service-connected disability. [Rationale]: a) There is no data in the [claims file] that document[s] the presence of an acute duodenal ulcer; b) the data that w[as] presumably used to diagnose the presence of peptic ulcer disease was the X-ray examination performed in [October] 1955 which was reported as having evidence of past, not active ulcers, with the presence of duodenal ulcer inferred, [not] confirmed. Since ulcer scarring is life-long, it should have been reported by the endoscopist [in April] 2007 but was not[,] [thus] adding further doubt to the [validity of the] original diagnosis. Rather, the Veteran had a history of duodenal polyp, diagnosed [in January] 2007, diagnosed by endoscopic ultrasound, which may have led to the original, but possibly erroneous radiographic diagnosis of ulcer scarring; c) since the service-[connected] disability classification may have been made on the basis of an erroneous diagnosis, it is difficult to support the statement "that the gastric carcinoma ha[d] its onset or was incurred [in] active service or [is secondary to] a service-[connected] disability. On the basis of the [claims file],. . . there is no firm evidence that the Veteran had an active ulcer, and even if he had, there is no evidence that [the] ulcer caused or aggravated [his] gastric cancer. It is not at least as likely as not (a 50% probability or greater) that the Veteran's duodenal ulcer caused or aggravated his gastric carcinoma. [Rationale]: [As discussed above, since] the diagnosis of duodenal ulcer disease is not supported by the [my review of the clinical evidence contained in the claims file], and since duodenal ulceration is considered to be protective against the subsequent development of gastric cancer, the statement "that the Veteran's duodenal ulcer caused or aggravated his gastric carcinoma" cannot be supported. [Dr. Frase stated in a May 2009 letter that the Veteran had a remote history of gastric ulcer, that clinical studies have demonstrated a common epidemiological risk factor association between gastric ulcer and gastric cancer, and that it is reasonable to assume there may be some relation between the Veteran's gastric cancer and his history of gastric ulcers. While the clinical evidence of a relationship between gastric ulcers and gastric cancer is indicated, as the Veteran was diagnosed with and service-connected for a duodenal ulcer, which involves a anatomical location different from where a gastric ulcer is located, Dr. Frase's statements are inapplicable to the Veteran's case. As previously stated, the evidence supporting a diagnosis of a peptic ulceration in general is weak, and since the Veteran is only service-connected for a duodenal ulcer, the connection between his duodenal ulcer and his subsequent development of gastric cancer cannot be supported. (Citations to medical authority omitted.) ] On the basis of analysis of the [claims file], there is no evidence that the Veteran's death was related to [his service-connected] duodenal ulcer disease, but rather to [his] gastric cancer. [It is] not at least as likely as not (a 50% probability or greater) that the Veteran's [service-connected duodenal ulcer]. . . caused, hastened, [or] substantially and materially contributed to his death, [or] combined to cause [his] death, or aided and lent assistance to the production of death by his service-connected duodenal ulcer. [Rationale]: [As discussed above, since] the diagnosis of duodenal ulcer disease is not supported by [my review of the claims file], and since duodenal ulceration does not increase the risk of the subsequent development of gastric cancer, the [clinical evidence does not support this conclusion.] The Board has considered the foregoing evidence. Firstly, the Board finds that the clinical evidence does not demonstrate that the Veteran's fatal gastric cancer, which was first diagnosed in 2007, had its onset during active service or was otherwise manifested to a compensable degree within the first year immediately following his discharge from active duty in September 1954. The appellant has not presented any evidence to the contrary. Continuity of symptomatology, as it would relate to gastric adenocarcinoma has not been objectively established either. Service connection for gastric adenocarcinoma on a direct or presumptive basis is therefore denied. As for the question of whether the Veteran's service-connected duodenal ulcer directly led to his death or the gastric carcinoma that ultimately led to his demise, the preponderance of evidence is against his claim as well. The February 2008 VA opinion and the May - June 2013 VA medical expert opinions collectively state the exact opposite. The February 2008 VA examiner's opinion found that the absence of the Helicobacter pylori bacterium on clinical testing indicated that an active peptic ulcer disease was not present. The February 2008 opinion also concluded that the Veteran's gastric cancer was less likely related to his service-connected duodenal ulcer but more likely caused by his lifelong history of excessive alcohol consumption and tobacco use. However, even assuming the validity of the duodenal ulcer diagnosis by history, the VA opinions conclusively demonstrate that the Veteran's service-connected duodenal ulcer is unrelated to his terminal gastric carcinoma as the duodenal ulcer. The VHA expert emphasized that the situs of the alleged duodenal ulcer, which is now questioned to have even existed, affected his duodenum, which is the connective junction between the stomach and small intestine. It is also an individual anatomical part separate and distinct from the stomach, which is the site of his fatal gastric adenocarcinoma. If anything, if the duodenal ulcer was, in fact, present, it would have conferred protection against the subsequent development of gastric cancer, thusly eliminating the clinical possibility that the service-connected duodenal ulcer caused or aggravated the Veteran's gastric cancer. The May - June 2013 VA medical expert's opinion found that it was more likely that the Veteran's "duodenal ulcer" was, in fact, a duodenal polyp, given the consistent absence of the Helicobacter pylori bacterium that is associated with peptic ulcer disease. The clinical evidence also does not demonstrate that this duodenal polyp was cancerous, as shown in the tissue biopsy report of January 2007. Ultimately, given the questionable validity of the duodenal ulcer diagnosis and the medical fact that duodenal ulceration does not increase the risk of the subsequent development of gastric cancer, the Board cannot conclude that the Veteran's service-connected duodenal ulcer caused, hastened, or substantially and materially contributed to his death, or combined to cause his death, or aided and lent assistance to the production of death. Consideration has been given to the opinion proffered by Dr. Frase. However, that opinion is at best equivocal. He only stated that there was "some" relationship between the Veteran's ulcer and gastric carcinoma. In that regard, Dr. Frase also acknowledged that drawing a relationship between the Veteran's ulcer and his gastric carcinoma was based on controversial studies. No other rationale was provided. Because the May - June 2013 VA opinion is presented by an established medical expert, is predicated upon his comprehensive review of the Veteran's pertinent clinical history and consideration of relevant medical authorities, and supported by a rationale that includes detailed discussion of the facts specific to the Veteran's individual case, the Board accords it significantly higher probative weight. The May - June 2013 VA opinion also incorporates all the prior opinions of record and has definitively reconciled any prior conflicting medical opinions and resolved any medical ambiguities associated thereto. He even referenced the findings made by Dr. Frase. The May - June 2013 VA opinion is therefore definitive for the issue of the relationship between the Veteran's period of active service and his death from gastric adenocarcinoma in May 2009. The opinion is also far more probative than that of Dr. Frase. The Board notes that in correspondence received by VA in March 2008, the appellant reported that she is a licensed registered nurse (R.N.). On her own credentials, she asserts that the late Veteran's death is related in some manner to his military service or his service-connected duodenal ulcer. Proper appellate review requires discussion of the medical opinion of the appellant herself where the facts indicate that she possesses at least some measure of medical training. Pond v. West, 12 Vet. App. 341 (1999). To the extent that the appellant asserts that her own personal knowledge of medicine and the Veteran's medical condition and history are sufficient in and of themselves to provide a basis to associate the Veteran's military service and/or his service-connected disabilities with his death, the Board notes that her expertise as a clinician is extremely limited. Assuming as true her self-reported credentials as an R.N., she is not shown to be an expert in gastrointestinal medicine and/or oncology. Therefore, her medical training does not confer upon her the level of expertise to present opinions on medical issues that would be possessed by a licensed physician with a medical degree. While the appellant is certainly competent to report the late Veteran's observable symptoms during his lifetime and up to the time of his death, including his subjective complaints of epigastric distress and self-medication with non-prescription antacids and stomach medications, she is not vested with sufficient medical training to possess the expertise and competence to state that these observed symptoms represented actual onset of gastric cancer in service or otherwise link his service-connected disabilities to his gastric cancer. Moreover, the determination of the cause of the Veteran's death, including the relative contributions of his long history of excessive alcohol abuse and tobacco use at the time of his death, is outside this appellant's expertise to address. Her statements in this regard therefore carry only very limited probative weight and, as such, are far outweighed by the expert medical opinions of record. In view of the foregoing discussion, the Board concludes that the weight of the objective medical evidence is against the appellant's claim of service connection for the Veteran's cause of death. The late Veteran's service-connected duodenal ulcer has been clinically determined to have not been a causal or substantially or materially contributing factor to his death, and his primary cause of death due to gastric adenocarcinoma is unrelated to his military service. Because the evidence in this case is not approximately balanced with respect to the merits of the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). At this juncture, the Board notes that the agency of original jurisdiction did not address any claim of entitlement to Dependency and Indemnity Compensation (DIC), pursuant to 38 U.S.C. § 1318. Usually, a claim for service connection for cause of death also includes a claim for § 1318 DIC. However, as the Veteran's right ankle fracture residuals (rated 20 percent disabling) and duodenal ulcer (rated 10 percent disabling) were his only service-connected disabilities and the ratings assigned to each are not currently intertwined with any pending increased rating claim for accrued benefits purposes, VA is not obligated to consider the matter of entitlement to § 1318 DIC. [See M21-1MR, Part IV, Subpart iii, Chapter III, Section D 19: The rating activity must consider entitlement to payment under 38 U.S.C. 1318 if service connection for cause of death is denied, and the veteran had a totally disabling service-connected condition at the time of death.] ORDER Service connection for the Veteran's cause of death is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs