Citation Nr: 1333485 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-47 507 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for skin cancer, to include basal cell carcinoma and squamous cell carcinoma, status post surgery. 2. Entitlement to service connection for skin cancer, to include basal cell carcinoma and squamous cell carcinoma, status post surgery. 3. Entitlement to service connection for sarcoma. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran had active military service from September 1941 to October 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland Ohio, which denied the matters on appeal. A July 2009 rating again denied these matters after additional evidence was submitted. However the Veteran's appeal is shown to be timely with the January 2009 rating decision, as the notice of disagreement was filed in October 2009, within a year of the January 2009 decision and the substantive appeal was filed in November 2010 within 60 days of receiving the statement of the case also in November 2010. In September 2013, the Veteran testified at a videoconference hearing conducted before the undersigned Veterans Law Judge (VLJ), who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107 (c) (West 2002 & Supp. 2013). A transcript of the testimony has been associated with the Veteran's claims file. To establish jurisdiction over the skin cancer claim, the Board must first consider whether new and material evidence has been received to reopen the claim. See 38 U.S.C.A. §§ 5108 , 7105 (West 2002). The Board must proceed in this fashion regardless of the RO's actions. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996) and VAOPGCPREC 05-92. As discussed fully under the analysis section, the Board finds that new and material evidence has been submitted sufficient to reopen the claim of entitlement to service connection for skin cancer, and will subsequently address this matter on the merits. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for sarcoma is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. By a June 2006 rating decision, the RO denied the Veteran's claim of service connection for skin cancer, on the basis that the evidence did not show that such was incurred in, or aggravated, by military service or had existed continuously since separation from service. 2. The evidence received since the June 2006 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for skin cancer, and raises a reasonable possibility of substantiating that claim. 3. The balance of the evidence reflects that the Veteran's skin cancer, at least as likely as not began in service. CONCLUSIONS OF LAW 1. The June 2006 rating decision that denied service connection for skin cancer is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.302 , 20.1103 (2013). 2. The evidence received subsequent to the June 2006 rating decision is new and material, and the claim for service connection for skin cancer is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2013). 3. Resolving all reasonable doubt in favor of the Veteran, service connection is warranted for skin cancer. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and To Assist VA has duties 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 and 3.326(a). In this case, the Board is reopening and granting in full the claim for service connection for skin cancer. Accordingly, even if error was committed with respect to either the duty to notify or the duty to assist as it pertains to the matter decided herein, such error was harmless and will not be further discussed. II. Claim to Reopen and Adjudication on the Merits The Veteran contends that his skin cancer is the result of sun exposure sustained in service while flying as a bombardier including conducting bombing training for the United States Army Air Corps during World War II. In this regard, the Board notes that service connection for this disorder was first denied by the RO in the June 2006 rating decision, with notice sent the same month. The Veteran was notified of this decision and of his appellate rights; however, he did not submit a notice of disagreement. In general, rating decisions that are not timely appealed become final. See 38 U.S.C.A. § 38 U.S.C.A. § 7105(d)(3). The Veteran, however, now seeks to reopen his claim. Despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is furnished with respect to the claim that has been disallowed. 38 U.S.C.A. §5108 ; 38 C.F.R. § 3.156(a). In October 2008, the Veteran requested that his claim for service connection for skin cancer be reopened. In order to reopen a claim that has been denied by a final decision, new and material evidence must be received. 38 U.S.C.A. § 5108. For applications to reopen filed after August 29, 2001, as was the application to reopen in this case, new and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness.). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Therefore, it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element, as it would "force the veteran to provide medical nexus evidence to reopen his claim so that he could be provided with a medical nexus examination by VA." Although it appears that the RO reopened the Veteran's claim for service connection for the above-referenced claim in the November 2010 Statement of the Case (SOC), the Board is not bound by that determination and is, in fact, required to conduct an independent analysis in claims involving final rating decisions. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). In this regard, using the guidelines discussed below, the Board finds that the Veteran has submitted new and material evidence. Accordingly, the claim of entitlement to service connection for skin cancer will be reopened. As previously noted, this claim was last considered and denied in a June 2006 rating decision, with notice received the same month. The evidence associated with the Veteran's claims file at the time of the June 2006 rating decision included some limited service treatment records, specifically a physical examination for flying dated in October 1941 which revealed the skin and lymphatics were normal. The complete service treatment records were noted to be unavailable as requests for records yielded a response in March 2006 that such records were not available due to having been destroyed in a fire in 1973. The Veteran's DD-214 previously before the RO document that his MOS was an AP Machine gunner for the period between September 1941 and March 28, 1945, and a second DD-214 shows that from March 29, 1945 to October 1945, he was a student officer with service schools attended to include flying school in Texas. Among the evidence considered by the RO, private medical records show treatment for skin cancers dating back to the early 1980's with a May 1984 diagnosing basal cell carcinoma (BCC) and noting a past history of treatment including with liquid nitrogen and MOH's surgery. A January 1986 letter noted a past history of carcinomas by Mohs technique, with recurrences presently involving his forehead extensively. In March 1986 he underwent surgical excision of lesions of the left ear, nose and forehead ,with a diagnosis of BCC of the nose and left ear, and a squamous cell carcinoma (SCC) of the forehead made by pathology in March 1986. In April 1986 he underwent surgical excision of the right temporal area and the right postauricular area, to include removal of skin tumors diagnosed as BCC's in these areas. Further surgical excision of BCC of the right forehead and nose was done in November 1986. In February 1988 he had a rapidly growing lesion under the left earlobe, with a letter from a private dermatologist describing a history of BCC's treated with surgery with probable BCC behind the left ear and within a depressed scar of the forehead. The doctor noted the Veteran to be of German-Irish ancestry, who grew up in Ohio, and had no history of arsenic exposure. He was noted to have served as a bombardier in B-29's stationed primarily in Florida and Texas. However no actual opinion of causation was made. In June 1989 he had a probable recurrence of BCC in the left ear. The evidence before the RO in June 2006 showed continued treatments and surgeries for skin cancer in the 1990's by private medical providers. In June 1991 the Veteran underwent surgery for recurrent and invasive BCC of the left ear and for squamous differentiation of the right neck, as confirmed by biopsy. The surgery essentially resulted in removal of the left ear. A September 1992 record disclosed the Veteran to have BCC in the right supra auricular sulcus. Private records throughout the 2000's received prior to June 2006 document ongoing problems with recurrences of skin cancers with a history in November 2001 of multiple BCC's in the head and neck region requiring surgical excisions and other modalities, with a near total auriculectomy on the left. His medical history was noted to include a history of flying the B-29 as a bombardier in World War II. Findings revealed a BCC of the right ear with excision recommended. A December 2003 record revealed he had not surgically treated the right ear BCC and in January 2004 he was recommended to undergo a right aureculectomy, but did not do so for nearly a year as a January 2005 follow-up noted an interval progression of the tumor of the right ear BCC, with the last visit a year ago. An April 2005 note revealed the Veteran to be 2 weeks status post right total auriculectomy and radical resection of the scalp for BCC of the posterior ear skin. VA treatment records from 2003 to 2005 previously before the RO in January 2006, also documented the history of treatment for multiple skin cancers, with a November 2003 primary care noting the Veteran to be under dermatological treatment for BCC and SCC of the right shoulder and AK's on his face. A November 2005 progress note revealed the Veteran to request assistance, with a history of being an 84 year old World War II bombardier, reporting no protection from the sun while flying those days around 40,000 feet. He described daily sunburns and reported a history of skin cancer for the past 20 years that he attributed to this sun damage. No opinion regarding causation of skin cancer was made by a medical professional. The Veteran's lay statement of March 2006, previously before the RO in June 2006, described exposure to sun in bombers including B-17's and B-24's in the locations where the bombardier sat. He said that the sun was hotter in high altitudes and that he was sunburned badly, mostly on the face and ears. He indicated sunscreen was not available for use in those days. Service personnel records submitted after June 2006 documents that the Veteran's military occupational specialty as student officer between March 1945 and October 1945 was as a bombardier instructor in Texas for a period of 4 months. The records also document the bombardier runs undertaken by the Veteran during this period. The evidence received after the RO's June 2006 decision documents continued treatment for BCC and SCC in various areas, mostly by private facilities. They also confirm that he underwent the procedure of total right auriculectomy, radical excision of the scalp and right selective neck dissection and reconstructive surgery for right postauricular and scalp BCC in March 2005. In January 2006 he was seen for Mohs consult for lesions on the right temple and right shoulder, present for several years and growing in size. His dermatological history was extensive and included removal of both ears and large skin grafts done. He was noted to have had blistering sunburns in the past, with a history that described him as a fighter pilot during World War II. In April 2008, the Veteran underwent surgical removal of a conjunctival and corneal SCC of the left eye. In October 2008 he was seen by the Head and Neck Institute for Facial Plastic and Reconstructive Surgery for follow-up of extensive scalp and tempural reconstruction following a resection of SCCA, with a current lesion left midface for which resection was recommended. In January 2009 he underwent additional major surgery including radical resection of malignant neoplasm of the right forehead and left temple/cheek, along with reconstructive surgery and grafting. Among the evidence submitted after the RO's June 2006 decision were 3 letters from private medical providers discussing the etiology of the Veteran's skin cancer. The first, a September 2008 medical opinion from Dr. B at Northcoast Dermatological services described treating the Veteran from December 2003 to January 2005 for BCC of the right ear and posterior scalp, with a history of multiple BCC's involving the head and back. These skin cancers were opined to be directly related to sun exposure. The Veteran was noted to state that he served as a bombardier during World War II and sun exposure during this period would be a contributing factor. The Veteran was noted to state that he was in training missions from 1944 to 1945 in Texas. The second letter an October 2008 letter from Dr. S at the Cleveland Clinic (which treated his cancers at various times), stated that the Veteran was diagnosed and treated for conjunctival and corneal SCC of the left eye in April 2008 and additionally had an extensive history of cancers including SCC requiring facial surgeries and reconstruction. This doctor remarked that it is well known that SCC of the conjunctiva is similar to SCC of the skin. This was related to excessive sunlight exposure as a pilot in WWII. The third letter, an October 2008 letter from Dr. F. from the Head and Neck Institute for Facial Plastic Reconstructive Surgery described the Veteran as being under his care for extensive facial/scalp reconstruction following resection of cutaneous SCC. The Veteran was noted to have multiple cutaneous malignancies resected and continued to have new ones. These included the majority of both external ears, left ocular conjunctiva and a significant portion of the scalp. This doctor understood the Veteran had extensive exposure to UV radiation flying high altitudes in the service as a bombardier/instructor in World War II, during which he suffered multiple episodes of severe burns of exposed skin. Certainly this type of exposure contributed to his current condition. An article submitted after June 2006 discussed UV radiation and described most skin cancers as a direct result of exposure to UV rays in the sunlight. A report of an October 2010 VA examination also received after June 2006 included review of the claims file and discussion of the multiple and extensive treatments of skin cancers dating back to 1986. The examiner noted the Veteran played golf from the 1950's. He was noted to report keeping a shirt on when he was at the beach when growing up. His service was noted to include flying 2 years and receiving multiple sunburns, treated by medical personnel. He indicated he wore a jumpsuit, jacket and cap and was an instructor/bombardier in Texas for 4 months. He was noted to be of German Irish Heritage. The examiner described his skin as Type 1, porcelain white skin type that always burned and never tans. This was described as the highest risk of skin cancer and wrinkling. The examiner noted there was a family history of skin cancer in his family, specifically his mother and father. Examination revealed multiple scaled plaques on the face and a 0.3 x 0.3 lesion on the left side of the forehead. There was scarring and/or disfigurement. There were multiple hypopigmented scars of the chest, back, shoulders, upper arms, scalp and face from previous procedures noted. These generally measured from 1-1.5 to 1-3.5 centimeters in diameter. A large scar that measured from 13 x 10 centimeters noted on the right posterior scalp. Also noted was a scar of the left temple that measured 7 x 0.2 centimeters, a scar of the left occipital area that measured 6 x 4 centimeters and a right temple scar that measured 5 x 4.5 centimeters. The examiner diagnosed actinic keratoses (AK), BCC and SCC. The examiner noted that the Veteran had a great deal of sun exposure in his life with excision of cancerous lesions from his chest and back, which were clearly covered when he flew aircraft in service. He often wore a jacket as it was cold at 42,000 feet. Thus these cancers would not be related because of exposure on active duty. The examiner gave an opinion that it was less likely than not that the Veteran's multiple skin cancers and treatments are related to his claimed exposure. Again he was noted to have a Type 1 skin type and was at high risk for skin cancer with his German Irish heritage. These factors were more likely than not the reason for his multiple skin cancers of the back, shoulders, etc. An addendum noted that the skin cancer presented in the 1980's more than 30 years after discharge which would make him in his late 50's or early 60's at the time of presentation. The addendum further stated that it was less likely than not that his current dermatological condition of skin cancers are secondary to claimed UV exposure during service, given the factors above. Further submitted after January 2006 was the Veteran's I-9 statement of November 2010 wherein he again alleged being treated in service for badly burned and blistered skin with Vaseline. His September 2013 hearing described his bombing training missions as involving 6 hour sessions positioned in a Plexiglas dome where the sun's rays were far more intense than on the ground. He conceded that he was fair skinned and sunburned easily as a child. He described that while flying his skin from the neck up was exposed. He indicated that his post service work which included insurance sales and real estate did not involve occupational sun exposure. He said that if service treatment records were available they would show treatment for sunburn with Vaseline. With these considerations, the Board has reviewed the record, with particular attention to the additional evidence received since the June 2006 rating decision. After reviewing the record, the Board finds that the additional evidence received since the final June 2006 rating decision is new and material within the meaning of 38 C.F.R. § 3.156(a). The majority of this evidence is certainly new, in that it was not previously of record. Most significantly the 3 letters from the Veteran's private doctors describing his in-service exposure to sunburns as causative factors in the development of his skin cancers now provide a medical nexus linking the skin cancer to service. Thus, the Board finds that new and material evidence has been presented to reopen his previously denied claim for service connection for skin cancer. This aspect of his appeal is, therefore, granted. Having reopened this claim, the Board shall now consider the Veteran's claim for entitlement to service connection for skin cancer on the merits. Generally, applicable law provides that service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1131; 38 C.F.R. §§ 3.303, 3.304. In addition, service connection may be granted for any disease 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). In order to establish service connection, a claimant must generally submit (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus or relationship between the current disability and the in- service disease or injury. Pond v. West, 12 Vet. App. 341, 346 (1999). Service connection may also be granted if the evidence shows that the condition was observed during service and continuity of symptomatology was demonstrated thereafter, and if the evidence includes competent evidence relating the current condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997); 38 C.F.R. § 3.303(b). Where a veteran served continuously for ninety days or more during a period of war, or during peacetime service after December 31, 1946, and cancer becomes manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status will not always constitute competent medical evidence. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran can attest to factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau, supra. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether the evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21. Vet. App. 303 (2007). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107. A Veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a Veteran seeks benefits and the evidence is in relative equipoise, the Veteran prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board notes that the evidence has been discussed at length above in discussing reopening this claim, and generally shows multiple occurrences of skin cancers diagnosed as BCCs and SCCs involving various areas, but most significantly extensively involving the head, neck and both ears. Such treatment has been ongoing since the 1980's. The evidence also includes the Veteran's lay evidence for which he is deemed competent to report as to his history of sustaining in-service injury of sunburns while flying as a bombardier instructor. His lay evidence is also deemed credible as he has repeatedly been consistent in describing the duties as a bombardier instructor and is also supported by the service personnel records showing such training flights. The evidence also includes the favorable opinions from three of the Veteran's treating doctors who in letters dated in September 2010 and October 2010, essentially have stated that his exposure to sunburns while serving in bomber training missions during World War II has been a causative factor in his developing these subsequent skin cancers. The Board also notes that the evidence includes the unfavorable opinion from the VA examiner in the October 2010 VA examination, with the examiner essentially stating that the skin cancer resulted from the Veteran's skin type and heritage. The examiner also appeared to rely heavily on the fact that the Veteran wore protective clothing that covered his chest and back, where some skin cancers have been located. The Board lends little weight to the VA examiners' opinion, as such opinion did not include discussion of the extensive skin cancer of the head and face in providing the unfavorable opinion. Again the examiner is noted to have focused on the areas of the back and chest and the fact that these areas were not exposed to the sun. The examiner did not address the fact that the Veteran's head was generally exposed except for a helmet. The Veteran has provided lay evidence describing that his head and neck were exposed. In contrast, the Board finds that the favorable opinions from the three treating doctors, who include medical experts in dermatology, reconstructive surgery and cancer treatment, included consideration of the Veteran's lay history of his sun exposure, which is shown to be credible. This lay history was considered in conjunction with their knowledge of the Veteran's medical condition and diagnoses during the course of treating him. Their favorable opinions are supported by sound rationale and credible patient history. Thus, for the reasons described above, the Board concludes that there is a reasonable doubt as to whether the Veteran's skin cancer is causally or etiologically related to his period of service. To the extent that there is any reasonable doubt, that doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board concludes that service connection for skin cancer is warranted. ORDER Entitlement to service connection for skin cancer is granted. REMAND Regarding the claim for entitlement to service connection for sarcoma, the Board finds that given the complexity involved in diagnosing cancers, further development is necessary to obtain clarification as to whether any of the Veteran's cancers treated meet the criteria for a diagnosis of soft tissue sarcoma and if so whether it is related to service. A review of the record is thus far negative for such a diagnosis of a sarcoma, and the VA examiner did not clearly provide an opinion as to whether any of the cancers treated meet the criteria for a sarcoma. The Board notes that VA adjudicators are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). Thus it is necessary to obtain such medical opinion to ensure proper adjudication of this claim for service connection for sarcoma, which is separate from the skin cancer claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (where the Court held that the scope of a service connection claim for a mental disability is not restricted to the specific diagnosis alleged by the claimant, but includes any mental disability which may reasonably be encompassed by the claimant's description of the claim, the reported symptoms, and other information of record). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO should arrange for the claims folder to be reviewed by an appropriate specialist. The claims folder and a copy of this remand must be reviewed by the examiner. The examiner is asked to clarify as to whether any of the cancers the Veteran has received treatment for meets the criteria for a diagnosis of a soft tissue sarcoma that is separate from the skin cancers of basal cell carcinoma or squamous cell carcinoma (for which service connection is now in effect). If the examiner determines that the diagnosis of soft tissue sarcoma is appropriate for any of the cancers treated, the examiner should determine whether it is at least as likely as not that the any soft tissue sarcoma became manifested during, or as a result of, active military service, to include as due to sun exposure while serving as a bomber instructor. In addressing this matter, the examiner must consider not only the evidence shown in the limited service treatment records, but also the lay history provided by the Veteran regarding his sun exposure (and which is noted to have supported a grant of service connection for skin cancers). A complete rationale for all opinions offered must be provided. (If the examiner concludes that an examination is required to provide the required opinions, another examination should be scheduled.) 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran's service connection claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. A. Markey Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs