Citation Nr: 1337221 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 10-05 998 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE Entitlement to service connection for the cause of the Veteran's death, to include as due to in-service contaminated water at Camp Lejeune. ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1974 to June 1977. During his active military service, the Veteran was stationed at Camp Lejeune in Jacksonville, North Carolina. The Veteran died on May [redacted], 2008. The Appellant is his surviving spouse. The Appellant's claim comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. FINDINGS OF FACT 1. The Veteran died in May 2008 from cardiopulmonary arrest due to metastatic renal cell carcinoma. 2. At the time of the Veteran's death, he was not service-connected for any disabilities. 3. During his active military service, the Veteran was stationed at Camp Lejeune during the period of time when the water was contaminated; thus, the Veteran was exposed to contaminated water during his active military service. 4. The evidence does not establish that the Veteran's death was causally related to his active military service, to include his exposure to contaminated water while stationed at Camp Lejeune. CONCLUSION OF LAW A disability of service origin did not cause or contribute substantially or materially to cause the Veteran's death. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1310, 5100, 5102, 5103, 5103A, 5106, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.312, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION 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, all of 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 claim. Equal weight is not necessarily accorded to each piece of evidence contained in the record; every item of evidence does not necessarily 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 claimant 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). Duty to Notify and Assist 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 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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, and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additionally, in the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, section 5103(a) notice must include: (1) a statement of the disorders, 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 DIC claim based on a previously service-connected disability; and, (3) an explanation of the evidence and information required to substantiate a DIC claim based on a disorder not yet service-connected. Hupp v. Nicholson, 21 Vet. App. 342, 352-53 (2007). While there are particularized notice obligations with respect to a claim for DIC benefits, there is no preliminary obligation on the part of VA to conduct a pre-decisional adjudication of the claim prior to providing a section 5103(a)-compliant notice. In this regard, the January 2009 letter informed the Appellant that she should provide "medical evidence showing that the Veteran's service-connected conditions caused or contributed to the Veteran's death." The letter further stated that to support a claim for DIC benefits, the evidence must show that the "Veteran died from a service-connected injury or disease." The letter also informed the Appellant that to establish DIC benefits, the evidence must show that the "Veteran died from a service-related injury or disease." Since the Veteran was not service-connected for any disabilities at the time of his death, the first Hupp element does not apply. By the same token, the second Hupp element does not apply, as it is predicated on the Veteran having been service-connected for a disability during his lifetime. Under the third Hupp element, the claimant must be notified of the evidence and information required to substantiate a DIC claim based on a disorder not yet service-connected. Regarding the third element, the notice provided in the January 2009 letter did not satisfy the third Hupp element. Hupp, 21 Vet. App. at 352-53. However, the Appellant has demonstrated actual knowledge of the information and evidence necessary to substantiate her claim by way of the arguments made to the RO and communications to the Board during the course of the current appeal. Specifically, the Appellant was aware that the Veteran was not service-connected for any disabilities during his lifetime, and understood that she needed to establish that the Veteran's death was due to his in-service water contamination at Camp Lejeune. In support of this argument, the Appellant submitted articles to VA regarding Camp Lejeune and its contaminated water. For these reasons, the Board finds that the Appellant had actual knowledge of the requirements necessary to establish the benefits sought and thus there is no prejudicial error. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Moreover, the Appellant has not alleged any prejudicial error in the content or timing of the VCAA notice she received. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Additionally, the notice letters provided did not include any information concerning the evaluation or the effective date that could be assigned should the claim be granted, as outlined in Dingess v. Nicholson, 19 Vet. App. 473 (2006). However, since this decision affirms the RO's denial, the Appellant is not prejudiced by the failure to provide her with that information. For all of these reasons, the Board concludes that the appeal may be adjudicated without a remand for further VCAA notification. VA also has a duty to assist the Appellant in the development of the claim. This duty includes assisting the Appellant in the procurement of the Veteran's service treatment records (STRs) and pertinent treatment records and providing a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Veteran's STRs and post-service private treatment records have been obtained. The claims file also does not present evidence that the Veteran was receiving disability benefits from the Social Security Administration (SSA) for his carcinoma prior to his death. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. See 38 U.S.C.A. § 5103A(a). The record indicates that a VA medical opinion was obtained in October 2012, the results of which have been included in the claims file for review. The VA medical opinion involved a review of the claims file and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the VA medical opinion is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the claim. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Appellant's claim. Therefore, no further assistance to the Appellant with the development of evidence is required. Analysis The Appellant contends that the Veteran's death from metastatic renal cell carcinoma was the result of his active military service, to include as due to in-service exposure to contaminated water at Camp Lejeune. According to applicable laws and regulations, service connection for the cause of a Veteran's death requires evidence that a service-connected disability was the principal or contributory cause of death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312(a). A service-connected disability will be considered the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A service-connected disability will be considered a contributory cause of death when such disability contributed substantially, or combined to cause death - e.g., when a causal (not just a casual) connection is shown. 38 C.F.R. § 3.312(c). Generally, minor service-connected disabilities, particularly those of a static nature or those not materially affecting a vital organ (e.g., those disabilities affecting muscular or skeletal functions), are not held to have contributed to a death that is primarily due to unrelated disability. Service-connected diseases or injuries affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other diseases or injury primarily causing death. 38 C.F.R. § 3.312(c)(2), (3). There are primary causes of death that by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting disorders, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected disability was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected disability accelerated death unless such disability affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4). At the time of his death, the Veteran was not service-connected for any disabilities. Thus, within this framework, the Board must consider the laws that otherwise govern the issue - i.e., establishing service connection for a disorder. Service connection may be granted if the evidence demonstrates that a current disorder resulted from an injury or disease that was incurred in or aggravated by the Veteran's active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Stated somewhat differently, to establish entitlement to service connection, there must be: (1) a diagnosis of a current disorder; (2) medical or, in certain cases, lay evidence of in-service occurrence of a disease or injury, or aggravation of a pre-existing disease or injury; and, (3) evidence of a nexus between an in-service injury or disease and the current disorder. Hickson v. West, 12 Vet. App. 247, 252 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including malignant tumors, will be presumed if they manifest to a compensable degree within one year following the active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. §§ 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Here, the death certificate shows that the Veteran died in May 2008 from a cardiopulmonary arrest due to metastatic renal cell carcinoma. There was no autopsy performed. The Veteran died in his private residence. The Veteran's STRs, including his military separation examination, do not contain any complaints of, findings of, or treatment for metastatic renal cell carcinoma or its related symptoms. In fact, the record does not contain evidence of the Veteran complaining of symptoms or seeking medical treatment for his metastatic renal cell carcinoma until February 2006, almost thirty years after his military service ended in June 1977. This intervening lapse of so many years between his separation from military service and the first documented manifestation of the disorder is probative evidence against the Appellant's claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Regarding the Appellant's assertion that the Veteran's death was due to his in-service exposure to water contamination while he was stationed at Camp Lejeune, VA acknowledges that there was contamination of the ground water at Camp Lejeune from 1957-1987. Specifically, in the early 1980s, it was discovered that two on-base water-supply systems were contaminated with the volatile organic compounds (VOCs) trichloroethylene (TCE), a metal degreaser, and perchloroethylene (PCE), a dry cleaning agent. The main source of TCE contamination was on-base industrial activities, while the main source of PCE was an off-base dry cleaning facility. Benzene, vinyl chloride, and other VOCs were also found to be contaminating the water-supply systems. These water systems served housing, administrative, and recreational facilities, as well as the base hospital. The contaminated wells supplying the water systems were identified and shut down by February 1985. The Agency for Toxic Substances and Disease Registry (ATSDR), a branch of the Department of Health and Human Services, conducted a Public Health Assessment of Camp Lejeune in 1997, which did not determine whether base personnel experienced any long-term health effects from consumption of the contaminated water. In 2008, the National Academy of Sciences' National Research Council (NRC) and ATSDR initiated studies. NRC undertook a study to assess the potential long-term health effects for individuals who served at Camp Lejeune during the period of water contamination. In the resulting report, Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects (June 2009), NRC reviewed previous work done by ATSDR, including computerized water flow modeling, and concluded that additional studies may not produce definitive results because of the difficulties inherent in attempting to reconstruct past events and determine the amount of exposure experienced by any given individual. To address potential long-term health effects, NRC focused on diseases associated with TCE, PCE, and other VOCs. Based on analyses of scientific studies involving these chemicals, NRC provided an assessment of the potential association between certain diseases and exposure to the chemical contaminants. The NRC analysis utilized categories of potential disease "health outcomes." The categories included: (1) sufficient evidence of a causal relationship; (2) sufficient evidence of an association; (3) limited/suggestive evidence of an association; (4) inadequate/insufficient evidence to determine whether an association exists; and, (5) limited suggestive evidence of no association. The analysis found that no diseases fell into the categories of sufficient evidence of a causal relationship or sufficient evidence of an association with the chemical contaminants. However, fourteen diseases were placed into the category of limited/suggestive evidence of an association. A number of diseases were also identified that fell into the category of inadequate/insufficient evidence to determine whether an association exists. NRC indicated that placement of diseases in these categories was based primarily on studies of highly exposed industrial workers, where the amount and duration of toxic chemical exposure greatly exceeded that experienced by individuals at Camp Lejeune. The specific diseases with limited/suggestive evidence of an association include: esophageal cancer; lung cancer; breast cancer; bladder cancer; kidney cancer; adult leukemia; multiple myeloma; myleodisplasic syndromes; renal toxicity; hepatic steatosis; female infertility miscarriage, with exposure during pregnancy; scleroderma; and, neurobehavioral effects. ATSDR responded to the NRC report in August 2009 with a plan for additional studies, supported by the Navy, to assess the human health risks associated with the Camp Lejeune water contamination. The plan included: a continuation of water flow computer modeling studies to generate potential contaminant exposure rates and durations; a re-analysis of data collected on birth outcomes; studies on birth defects and childhood cancers; and, further epidemiological studies based on mortality and health surveys that would be distributed to former Camp Lejeune residents. ATSDR also initiated a series of public hearings to receive input from individuals who had served at Camp Lejeune. In a 2010 letter to the Navy, ATSDR again responded to the NRC report, indicating its belief that the report minimized the potential long-term health effects of exposure to the water contamination. The letter stated the view that "there was undoubtedly a hazard associated with drinking the contaminated water at Camp Lejeune." ATSDR pointed out that, although the NRC report found only limited/suggestive evidence for any diseases associated with the contaminated water, other scientific organizations considered the contaminants to be carcinogenic. For example, regarding TCE and PCE, the International Agency for Research on Cancer (IARC) classifies them as "probable human carcinogens" while the National Toxicology Program (NTP) refers to them as "reasonably anticipated to be a human carcinogen." Additionally, both IARC and NTP label benzene and vinyl chloride as "known human carcinogens." Although the ATSDR letter emphasizes the fact that the water contaminants themselves have been generally associated with potential carcinogenic health outcomes in humans, there is currently only speculation as to the extent of exposure and actual effects on the population at Camp Lejeune. ATSDR has indicated that its planned studies, making use of computerized water flow modeling and the epidemiological mortality and health survey, will provide a higher level of exposure predictability and definable health outcomes than are recognized as possible by NRC. However, to date, the results of any additional studies have not been made available. As noted, a number of diseases have been identified as being associated with exposure to the specific Camp Lejeune water contaminants, based on human and experimental animal studies. Manifestation of any of those diseases is considered to be sufficient to initiate a VA medical examination and request an opinion regarding its relationship to Camp Lejeune service. However, this is not an exclusive list. Medical evidence provided by a Veteran indicating that some other disease may be related to the known water contaminants could also be sufficient to initiate a VA examination. It is important to note that to date, no definitive scientific studies have provided conclusive evidence that an individual who served at Camp Lejeune during the period of water contamination developed a particular disease as a result of that service. Many unanswered questions remain regarding the levels of water contamination at various base locations, the amount and type of exposure experienced by any given Veteran who served there, and the scientific probability that a Veteran's particular claimed disease resulted from the service at Camp Lejeune rather than from some other source. As a result, there are currently no "presumptive" diseases attributed to service at Camp Lejeune by statute, regulation, or VA policy. Accordingly, when VA receives a claim based on chemical exposure at Camp Lejeune, VA first must determine if the Veteran was stationed at Camp Lejeune and if so for how long and in what capacity. Here, the evidence establishes that the Veteran was stationed at Camp Lejeune during a portion of his active military service from June 1974 to June 1977, as documented on his DD-214 Form. The next step is to verify, with medical evidence obtained through a VA medical examination or other authoritative medical sources, whether a claimed current disease or disability is at least as likely as not a result of exposure to the chemical compounds present in the water at Camp Lejeune. In this regard, on an October 2008 "Claim for Damage, Injury, or Death" form, Dr. G., a private physician who had treated the Veteran prior to his death, wrote, "Renal cell carcinoma resulting in death second to metastatic cancer cannot exclude a causal relationship with the patient's reported exposure to PCE and TCE." Dr. G. provided no further rationale and did not review the Veteran's claims file prior to providing his medical opinion. It is also unclear from the statement as to the exact causal relationship that the physician is referring to, as the physician does not mention Camp Lejeune or the Veteran's active military service in his statement. There are a line of precedent cases discussing the probative value of opinions like this that are equivocal, which essentially state that it is possible the disorder at issue is attributable to the Veteran's active military service. See, e.g., Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Perman v. Brown, 5 Vet. App. 227, 241 (1993); Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Winsett v. West, 11 Vet. App. 420, 424 (1998). These cases make clear that, while an absolutely accurate determination of etiology is not a condition precedent to granting service connection, nor is definite etiology or obvious etiology, a doctor's opinion phrased in terms tantamount to "may" or "could" be related to service is an insufficient basis for an award of service connection because this is for all intents and purposes just like saying the condition in question just as well "may or may not"" be related to service. Obert v. Brown, 5 Vet. App. 30 (1993). See, too, Bloom v. West, 13 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Thus, based on this case law, the private medical statement is insufficient medical evidence to substantiate the claim. Accordingly, based on this suggestive private opinion, in October 2012, the Veteran's claims file was sent to a VA examiner. Following a review of the claims file, the examiner determined that the metastatic renal cell carcinoma was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The October 2012 VA examiner reasoned that, according to OmnimedicalSearch.com, medical researchers have not been able to identify the exact causes of renal cell carcinoma, but the evidence from clinical trials and medical experience reveals a strong connection between several risk factors. Specifically, the examiner stated that renal cell carcinoma is more common among men, more common between ages 40-60, and is increased in patients who are obese. It is also known that smoking increasing the likelihood of renal cell carcinoma by 40 to 50 percent. Occupational risk factors include exposure to asbestos, such as is found in insulation and cadmium used in batteries, in workplace (not casual) exposure to TCE, and in the plastic industry. Hypertension also increased the risk of developing the disease, according to one research investigation. The examiner noted that renal cell carcinoma comprises 2 percent of the total cancers diagnosed each year in North America, but it is on the rise per "ACA" since the 1970s. In fact, the examiner stated that renal cell carcinoma is the most common type of kidney cancer, comprising 9 out of every 10 cases found and is in the top 10 most common types of cancers in the United States. The October 2012 VA examiner continued by stating that the Veteran's exposure to TCE and PCE, along with benzene, vinyl chloride and chromium, is conceded due to his being stationed at Camp Lejeune. However, the examiner pointed out that the Veteran was a significant smoker of over thirty years versus his three year exposure to the varying levels of contaminants in the water at Camp Lejeune. Cigarette smoke contains over 4000 different chemicals, including benzene, hydrocarbons, aldehydes, toluene and other chemicals known to be carcinogens. TCE can be produced in a two-step process from at least one of the chemicals found in cigarette smoke. In fact, according to the examiner, one recent review of the epidemiology of kidney cancer rated cigarette smoking and obesity as more important risk factors than exposure to solvents such as TCE. Each cigarette smoked exposes the patient to 5.9-75 micrograms of benzene, for example. It is also known that the greater the exposure to carcinogens, the higher the risk for developing the disease. The examiner found that the Veteran's comorbid conditions clearly indicated a very large exposure to similar carcinogens through smoking for ten times the length of time of exposure at Camp Lejeune, which was relatively short-term and intermittent. The rotation of the various wells at Camp Lejeune makes it difficult to estimate the actual amount of exposure, which varied considerably from sample to sample. However, the examiner stated that the Veteran's occupational exposure as both electrician working with metal wiring, batteries (cadmium), plastic coatings on wires, around insulation, and in manufacturing cabinets whose surface sealants were also likely to contain carcinogenic potentials, along with working in home renovation, placed him at additional risk for renal cell carcinoma. Epidemiologic data derived largely from occupational exposures at higher, longer term exposures to TCE and PCE has not generated compelling evidence of adverse health effects per the National Academy of Sciences. In summary, the October 2012 VA examiner found that, based on the Veteran's short-term and intermittent exposure to the water contaminants versus his thirty years of cigarette smoking, the confounding factor of occupational risk, and the presence of other factors, such as a body mass index (BMI) greater than 28 around the time of diagnosis with Stage IV disease, makes it appear less likely than not that the Veteran's renal cell carcinoma was triggered by his exposure to water contaminants found in the Camp Lejeune water supply in the mid-1970s. There are no other medical opinions regarding this issue in the claims file, and the treatment records do not provide contrary evidence. Thus, there are no medical opinions in the claims file clearly attributing the Veteran's metastatic renal cell to his active military service, to include his in-service contaminated water exposure. The medical evidence of record, as a whole, does not substantiate the Appellant's lay assertions that the Veteran's active military experience, including his exposure to contaminated water, caused his eventual death from metastatic renal cell carcinoma. The record also does not document continuous symptomatology of a malignant tumor since the Veteran's active military service. As stated above, the earliest pertinent post-service medical evidence associated with the claims file is dated from February 2006, almost thirty years after the Veteran's military separation in 1977. Further, the STRs do not show that the Veteran developed a chronic malignant tumor during his active military service. The STRs do not document any complaints of or treatment for a malignant tumor or its associated symptoms. Additionally, when the Veteran was first treated post-service in February 2006 by his private physician, he did not indicate that he had been suffering from renal cell carcinoma since his active military service. Thus, the evidence of record does not document continuity of symptomatology during and since the Veteran's active military service. Thus, the Board finds that the medical evidence does not establish a "chronic disorder." 38 C.F.R. § 3.303; see Walker, 708 F.3d at 1331. The service connection claim also cannot be granted on this theory of entitlement. Additionally, the Board finds that the Veteran is not entitled to presumptive service connection for malignant tumors. As stated above, the earliest post-service medical treatment records are dated from February 2006, and the Veteran was separated from the active duty in 1977. No diagnosis of a malignant tumor or metastatic renal cell carcinoma was made within one year of the Veteran's military discharge. Thus, the presumption for service connection for chronic diseases does not apply. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In reaching this decision, the Board has considered the Appellant's arguments and articles submitted in support of her assertions that the Veteran's metastatic renal cell carcinoma is related to his active military service, to include his presumed in-service contaminated water exposure. It is true that the Appellant's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of the disorder or symptoms of the disorder subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disorder even where not corroborated by contemporaneous medical evidence); Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"). However, metastatic renal cell carcinoma is a complex disease entity that requires specialized training for a determination as to diagnosis and causation, and is therefore not susceptible to lay opinions on etiology. In summary, as noted above, the Veteran was not service-connected for any disabilities during his lifetime. In addition, the Board finds that the probative evidence of record does not show that a disorder incurred in or aggravated by the Veteran's active military service either caused or contributed substantially or materially to his death. Therefore, service connection for the cause of the Veteran's death must be denied. The benefit-of-the-doubt rule does not apply, and the Appellant's claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see Alemany v. Brown, 9 Vet. App. 518, 519 (1996). ORDER Entitlement to service connection for the cause of the Veteran's death, to include as due to in-service water contamination at Camp Lejeune, is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs