Citation Nr: 1453576 Decision Date: 12/04/14 Archive Date: 12/10/14 DOCKET NO. 99-05 155 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for adenocarcinoma of the prostate, to include as due to exposure to ionizing radiation. 2. Entitlement to service connection for degenerative joint disorders, to include as due to exposure to ionizing radiation. REPRESENTATION Veteran represented by: Stephen S. Pennington, Esq. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. B. Yantz, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1949 to October 1952. These matters are before the Board of Veterans' Appeals (Board) on remand from the United States Court of Appeals for Veterans Claims (Court). The case was originally before the Board on appeal from a December 1998 rating decision of the Philadelphia, Pennsylvania Department of Veterans Affairs (VA) Regional Office (RO). In November 2000, a Travel Board hearing was held before the undersigned, and a transcript of the hearing is associated with the record. In a decision issued in November 2001, the Board denied service connection for adenocarcinoma of the prostate and degenerative joint disorders. The Veteran appealed that decision to the Court. In May 2003, the Court issued an order that vacated the November 2001 Board decision and remanded the matters on appeal for readjudication consistent with its instructions. In December 2003, the case was remanded for additional development in accordance with the Court's May 2003 order. In December 2010, a Decision Review Officer (DRO) at the RO held an informal conference via telephone with the Veteran's attorney. In May 2011, the case was again remanded for additional development. In a decision issued in August 2013, the Board denied service connection for adenocarcinoma of the prostate, and remanded the claim of service connection for degenerative joint disorders. The Veteran appealed the portion of that decision which denied service connection for adenocarcinoma of the prostate to the Court. In June 2014, the Court issued an order that vacated the August 2013 Board decision with respect to the denial of service connection for adenocarcinoma of the prostate, and remanded that matter for readjudication consistent with the instructions outlined in a June 2014 Joint Motion for Remand (Joint Motion) by the parties. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of service connection for degenerative joint disorders is being REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if action on his part is required. FINDING OF FACT Adenocarcinoma of the prostate was not manifested in service or in the first postservice year, and the preponderance of the evidence is against a finding that any current adenocarcinoma of the prostate (or residuals) is related to the Veteran's service, to include as due to his exposure to ionizing radiation therein. CONCLUSION OF LAW Service connection for adenocarcinoma of the prostate, to include as due to exposure to ionizing radiation, is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.311 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The initial adjudication in this matter preceded the enactment of the VCAA. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that where notice was not mandated at the time of the initial AOJ decision, the AOJ did not err in not providing the notice prior to the initial adjudication; instead, the claimant had a right to timely content-complying notice and proper subsequent VA process. April 2004, April 2007, and March 2013 letters explained the evidence necessary to substantiate the Veteran's claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. The April 2007 and March 2013 letters also informed the Veteran of disability rating and effective date criteria. Most recently, an April 2013 supplemental statement of the case (SSOC) readjudicated the matter after the Veteran and his attorney responded and further development was completed. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (VCAA timing defect may be cured by the issuance of fully compliant notification followed by readjudication of the claim); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). At the hearing before the undersigned, the Veteran was advised of the criteria for establishing service connection for adenocarcinoma of the prostate, to include as due to exposure to ionizing radiation. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). He has received all critical notice, and has had ample opportunity to respond/supplement the record. It is not alleged that he has been prejudiced by a notice error or omission. The Veteran's service treatment records (STRs) and postservice private treatment records have been secured. The RO arranged for a pertinent VA examination in December 2007, with an addendum medical opinion in March 2009. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The RO also obtained pertinent medical opinions from the Under Secretary for Health in November 1998, April 2001, and May 2007, as well as pertinent advisory opinions from the Director of Compensation and Pension (C&P) Service in December 1998, May 2001, June 2007, and April 2009. VA attempted to obtain all records pertaining to the Veteran from the Social Security Administration (SSA); however, SSA responded in April 2013 that they possessed no records pertaining to the Veteran, as all such records had been destroyed after seven years of inactivity. The Board has determined that VA's development has been exhaustive, and that any further attempts at development for such records would be fruitless. Following the issuance of the Court's May 2003 order, all of the relevant development requested by the Board's December 2003 and May 2011 remands was fully completed with regard to the issue being decided on appeal, and therefore the remand orders were fully complied with. See Stegall v. West, 11 Vet. App. 268 (1998). In addition, by fully addressing the favorable medical opinions of record in the Analysis section below, to include outlining why such opinions are not persuasive, the Board has implemented the instructions outlined in the June 2014 Joint Motion. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. Legal Criteria Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge may still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Establishing service connection requires evidence of: (1) a current disability; (2) a disease; injury, or event in service and (3) a nexus between the claimed disability and the disease, injury, or event in service and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Some chronic diseases (to include malignant tumors) may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within a specified period of time post-service (one year for malignant tumors). 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection for a disability that is claimed to be due to exposure to ionizing radiation during service can be demonstrated by one of three possible methods. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are certain types of cancer presumptively service-connected that are specific to radiation-exposed veterans. 38 U.S.C.A. § 1112(c); 38 C.F.R. § 3.309(d). Second, a "radiogenic disease" may be service-connected pursuant to 38 C.F.R. § 3.311. Third, direct service connection may be granted under 38 C.F.R. § 3.303(d) when it is established that a disease diagnosed after discharge from service was otherwise incurred during active service, including as a result of exposure to radiation. See Combee, 34 F.3d at 1039. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Competent medical evidence may include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background The Veteran contends that he developed adenocarcinoma of the prostate as a result of exposure to ionizing radiation during his military service. Specifically, he has reported that he witnessed atomic bomb tests while performing his duties as a radio operator at Enewetak during Operation GREENHOUSE in June 1951. The Veteran's STRs, including partially burned originals and copies of partially burned records, are silent for any complaints, findings, treatment, or diagnoses relating to his prostate. The separation medical history, partially missing or illegible because of fire loss or scorching, included the Veteran's report of having worked with radioactive substances: "Washing B-17's after flying [missing] atomic cloud - Jan - to June [missing]." A March 1980 letter to the Veteran from the Defense Nuclear Agency (DNA) mentioned his participation in the atmospheric testing of nuclear weapons. The letter noted the DNA's research indicating that the average radiation dosage received by Department of Defense test participants was 0.5 rem, with over 99 percent of participants receiving less than 5 rem, the annual exposure permitted by federal regulation for radiation workers. An October 1983 report from the United States Air Force (USAF) Occupational and Environmental Health Laboratory (AFSC) confirmed the Veteran's participation in Operation GREENHOUSE, but noted that he was not included in the dosimetry records of the Reynolds Electrical and Engineering Company (REECo) for that test or for any other place or time. The Veteran's records were noted to be mostly destroyed in a 1973 fire at the National Personnel Records Center (NPRC); his affirmative report of "working with" radioactive substances was noted. The USAF Master Radiation Exposure Repository had no record of occupational or other radiation exposure of the Veteran in service. The Air Force reported that there was radioactive fallout on Enewetak Atoll during Operation GREENHOUSE, and that based on a memorandum used by the Air Force, "Calculated Radiation Doses for Island-Based Personnel, Operation GREENHOUSE and Thereafter," the Veteran was assigned a fallout radiation dose of 4.230 rem. The Air Force further reported that the Veteran was a Ground Radio Operator assigned to the 3200th Drone Squadron, Eglin Air Force Base (AFB), on temporary duty with his unit to Enewetak Atoll from January to June 1951 and that he was present for all four shots of Operation GREENHOUSE. An undated DNA Fact Sheet for Operation GREENHOUSE summarized the time, place, purpose, radiation exposure of film badges issued to certain participants in Operation GREENHOUSE, and fallout exposures of all participants based on their location and length of stay at Enewetak Atoll. Fourteen untitled, nonconsecutive pages of what appear to be one or more reports of an Advisory Committee to the Human Radiation Interagency Working Group (HRIWG), include findings that troop participants in atomic detonation tests were the subject of both training and research objectives, with mention of Operation GREENHOUSE (p. 459), and that in the Veterans' Dioxin and Radiation Exposure Compensation Standards Act of 1984, Congress found a failure of radiation dosimetry from film badges issued to personnel at atmospheric nuclear tests to measure internal doses, although DNA now can reconstruct individual estimates of such doses. In April 1997, a private laboratory test and biopsy confirmed a diagnosis of prostate cancer for the Veteran. In June 1997, the Veteran had bilateral staging pelvic lymphadenectomy, and radical perineal prostatectomy with en bloc bilateral seminal vesiculectomy for clinically localized adenocarcinoma of the prostate. Pathology diagnosis was right pelvic lymph node negative for metastatic tumor; left pelvic lymph node the same; and prostate with moderately differentiated adenocarcinoma. In a June 1997 statement, the Veteran's urologist (Dr. S.C.F.) reported that the Veteran had cancer of the urinary tract located in the prostate, treated surgically, and extending beyond the margins of resection. He stated, "[A]lthough we will never know the cause of these cancers, there was some suspicion that he [the Veteran] was exposed to radiation during 'Operation Greenhouse' at Bikini Island and Enimetok [sic]." In a December 1997 statement, a Professor of Pathology at Harvard Medical School (Dr. J.G.S.) noted that, while no data can irrefutably prove the causal etiology of a tumor in an individual, there were strong data to support a link between ionizing radiation exposure and the subsequent development of urinary tract malignancies, with much of the epidemiologic data derived from follow-up studies of atomic bomb survivors of Hiroshima and Nagasaki. He acknowledged that in one study, which showed a relative risk of 2.02 for urinary tract neoplasms in A-bomb survivors, some of the cancers were bladder carcinomas, but stated there was suggestive evidence that other urinary tract malignancies, including prostate cancer, could result from excessive exposure to ionizing radiation. He reported that there were 25 prostate neoplasms, including 19 adenocarcinomas and other adenomatous tumors in a population of 100 mice given a single dose of x-radiation; that a control population had 25 times fewer neoplasms; that there were adenomatous prostate tumors in dogs that received prolonged gamma radiation; and that there was an increased incidence of prostate cancer in a cohort of Air Canada pilots, a group chronically exposed to high altitudes and in- flight radiation, in striking contrast to the decreased incidence in this cohort of all other cancers. He stated that these data should be taken into consideration when reviewing the Veteran's claim. In a January 1998 statement, an Assistant Professor in the Department of Radiation Oncology at Bodine Center for Cancer Treatment (Dr. R.K.V.) noted that the Veteran had been exposed to multiple nuclear bomb test blasts with prolonged ionizing radiation, and that the Veteran's multiple medical problems included prostate carcinoma. He stated that while he could not prove with certainty that this condition had been caused by the Veteran's exposure to ionizing radiation, "it is within the realm of possibility, and very probable that [this] medical ailment is secondary to ionizing radiation." He noted that "[i]t has been reported that radiation can cause the development of malignancies, including prostate cancer," and he was especially suspicious of this etiology in the Veteran, because he lacked a family history of prostate cancer. Dr. R.K.V. opined further that radiation treatment of the Veteran's prostate cancer would be highly beneficial, but that such therapy was not a reasonable option in light of the past radiation exposure. In a January 1998 letter to Dr. S.C.F., an Assistant Professor in the Department of Urology at Jefferson Faculty Foundation (Dr. S.E.S.) noted the Veteran's medical history and opined, "It is certainly within the realm of possibility that his radiation exposure may have triggered his prostate cancer. There is little evidence to point to radiation specifically, but we certainly know the importance of environmental influence on prostate cancer. There is some experimental data as was outlined by [Dr. J.G.S.] from the Dana Farber Institute regarding experimental evidence linking ionizing radiation to the generation of prostate cancers." In a statement to VA on the same date in January 1998, Dr. S.E.S. reported that the Veteran had outlined the events surrounding his history of radiation exposure during military service. He stated he tended to agree with Dr. J.G.S.'s letter regarding the difficulty of establishing a specific event as the cause of any specific tumor, especially prostate cancer, because of its prevalence in aging men. Dr. S.E.S. noted that being Caucasian and without a family history of prostate cancer placed the Veteran in a low-risk group. These low-risk factors, together with the data discussed by Dr. J.G.S., made it "certainly within the realm of possibility that [the Veteran's radiation] exposure during his military service has certainly increased his cancer risk for not only skin malignancies but perhaps prostate malignancy as well." In a February 1998 statement, Dr. S.C.F. opined that the Veteran's prostate cancer "may have been very well linked to his exposure [to radiation] during his service career in the South Pacific." He referenced life-span studies by the RERF on Hiroshima and Nagasaki A-bomb survivors who demonstrated significant excess of cancers relative to unexposed zero-dose population, including cancers of the urinary tract, and stated that the Veteran fell within this category. In April 1998, VA requested that the Defense Special Weapons Agency (DSWA) provide reconstructed dosimetry for the Veteran's participation in Operation GREENHOUSE. It was noted that the Veteran's special orders indicated he had been a Ground Radio Operator assigned to the 3200th Drone Squadron, Eglin Air Force Base, on temporary duty with his unit to Enewetak Atoll from January to June 1951, and was present for all four shots of the operation. A June 1998 letter from Dr. A.C. to Dr. S.C.F. reported that the Veteran had completed a course of external beam megavoltage radiation therapy to the prostatic bed for carcinoma of the prostate, status-post radical prostatectomy with rising PSA values, which was initiated in April 1998. In August 1998, DSWA provided a Radiation Dose Assessment for the Veteran's participation in Operation GREENHOUSE. The reconstructed dose from residual fallout at Enewetak for external exposure was estimated as 0.00 rem of neutron radiation and 3.7 rem to 4.3 rem of gamma radiation. The report described the method used to reconstruct doses of internal radiation exposure to various organs. The Veteran's total committed dose equivalents to the prostate, bladder, and bone were less than 0.1 rem. DSWA also provided the executive summary from Review of the Methods Used to Assign Radiation Doses to Service Personnel at Nuclear Weapons Tests, National Academy Press (Washington, D.C. 1985). The summary reported that early (1950's) estimates of internal doses from inhalation or ingestion of radioactive material, based on incorrect extrapolations from external doses, tended to overestimate internal doses, with newer evidence indicating such doses from internal emitters were much lower than the external doses for all organs except the thyroid. In November 1998, the Director of C&P Service referred the Veteran's claim to the VA Under Secretary for Health for an opinion regarding the relationship between the Veteran's radiation exposure and his adenocarcinoma of the prostate. In November 1998, VA's Chief Public Health and Environmental Hazards Officer (CPHEHO) (Dr. S.H.M.) responded to the memorandum from VA's C&P Service. After noting the August 1998 radiation dose estimates from DSWA, she also noted that the CIRRPC Science Panel Report Number 6, 1988, did not provide screening doses for prostate cancer, and stated that the sensitivity of the prostate to radiation carcinogenesis appeared to be relatively low and not clearly established. Based on the foregoing, she opined that it was unlikely the Veteran's prostate cancer could be attributed to his exposure to ionizing radiation in service. The report cited references and authorities for its data, findings, and conclusions. In a December 1998 opinion, the Director of C&P Service stated that the Under Secretary for Health had reviewed the Veteran's claims file to provide an opinion about the relationship between the Veteran's exposure to ionizing radiation in service and his prostate cancer. Following review of the medical evidence of record, including opinions offered in support of the Veteran's claim and the cited studies, it was the opinion of the Under Secretary for Benefits that there was no reasonable possibility that the Veteran's prostate cancer disability was the result of his radiation exposure in service. In February 1999, the Veteran submitted materials from the National Association of Atomic Veterans, a group whose members are comprised of Veterans exposed to ionizing radiation from atomic and nuclear testing by the United States. He also submitted statements from such members, apparently compiled for dissemination to members of an affinity group and the general public. The documents include lay statements and histories about nuclear tests, including Operation GREENHOUSE, and the activities and experiences of participants, including voluntary, self-reported medical histories. A report on the solicitation of voluntary contributions to a medical data base reported the collection of morbidity data on 3.74 percent of the participants in Operation CROSSROADS, and several extrapolations from the data. The report commented that similar percentages were seen "for the most part" in data on Operation GREENHOUSE. On the Veteran's February 1999 VA Form 9, he argued that the government had underestimated his exposure to ionizing radiation, and stated, "Moreover, since no level of exposure to ionizing radiation is safe, and since no other causes or risk factors are apparent, it is more likely than not my illnesses are due to my military service." He asserted that his unusual combination of illnesses increased the likelihood that exposure to ionizing radiation in service was the cause of his claimed disorders, and that this was the only plausible explanation for his state of health. Referencing Dr. R.K.V.'s January 1998 report, the Veteran noted that his past radiation exposure interfered with cancer therapy, and asserted that such interference was (in and of itself) a service-connected injury. In a May 1999 statement, one of the Veteran's fellow soldiers (K.N.) reported that he was stationed with the Veteran on Enewetak Atoll during Operation GREENHOUSE, where they witnessed and assisted in monitoring the explosion of three atomic bombs and one hydrogen bomb, all within a 15 mile radius, and that the Veteran was exposed to hot radiation. He reported that the Veteran's duty was to care for and check hot drones that had passed through the radioactive clouds. K.N. reported that the Veteran's exposure was greater than his own, and that he himself had bladder cancer which was service- connected. K.N. reported that after the fourth detonation, all traffic to the island was cut off for three weeks while the island was under a radiation cloud that did not leave until a typhoon passed through the area. He reported that protective gear was minimal, and that they lived in exposed, 10-man tents. At his November 2000 hearing, the Veteran testified that he had no history of industrial employment that would have exposed him to chemicals or "anything like that." He reported that he was one of six siblings, the others ranging from 67 to 75 years of age, none with any history of cancer, and that there was also no history of cancer in his child, parents, nieces, or nephews. The Veteran and his attorney were advised at the hearing that VA's analysis of the effect of ionizing radiation on the Veteran had been based on reconstructed dosimetry, whereas Dr. J.G.S. and Dr. R.K.V.'s medical opinions lacked any independent dose estimates or references to the Veteran's individual radiation doses in service; and that this left the record silent as to whether their statements were informed opinions based on the Veteran's specific radiation dosages in service. In a December 2000 statement, Dr. J.G.S. reported he had reviewed the Veteran's radiation dose assessment and records. He stated that there were strong data to support a link between ionizing radiation exposure and subsequent development of urinary tract malignancies. He reiterated his December 1997 report of findings from studies of atomic bomb survivors of Hiroshima and Nagasaki, and of Air Canada pilots. He noted that in a study of over 39,000 employees of the United Kingdom Atomic Energy Authority between 1946 and 1979, prostate cancer was the only condition with a clearly increased mortality in relation to radiation exposure. He also cited several animal studies which linked ionizing radiation to the subsequent development of prostate cancer. Dr. J.G.S. opined that these data strongly supported a relationship between radiation exposure and the development of carcinoma of the prostate, and indicated they were relevant to the Veteran's claim. In a December 2000 statement, Dr. R.K.V. repeated (practically verbatim) the contents of his January 1998 statement. In April 2001, the Director of C&P Service referred the Veteran's claim to the VA Under Secretary for Health for another opinion, explaining that the Veteran had submitted several medical opinions that were not discussed and weighed in its prior November 1998 opinion. It was also noted that since the November 1998 opinion, the Veteran had submitted additional medical opinions that needed to be reviewed and addressed. In April 2001, VA's CPHEHO (Dr. S.H.M.) again reviewed the Veteran's claim file, including the December 2000 statement by Dr. J.G.S. and the literature cited by Dr. J.G.S. in his December 1997 and December 2000 statements. Dr. S.H.M. again noted the August 1998 DSWA dosimetry estimates. Regarding Dr. J.G.S.'s opinion, she contrasted the studies to which he had cited with other epidemiological studies that found no increases or non-statistically significant increases of prostate cancer. She also discounted the animal studies which he had cited, stating that their relevance for humans was uncertain, and noted that based on data cited in the Agency for Toxic Substances and Disease Registry report, Toxicological Profile for Ionizing Radiation, 162 (1999), it was estimated that there was about a 3 percent likelihood that development of cancer of the prostate could be attributed to the doses of radiation in the prostate that the Veteran was reported to have received. Dr. S.H.M. concluded that for the stated reasons and those in the November 1998 opinion, it was the opinion of VA's CPHEHO that it was unlikely that the Veteran's prostate cancer could be attributed to exposure to ionizing radiation in service. In a May 2001 opinion, the Director of C&P Service stated that the Under Secretary for Health had reviewed the Veteran's claims file to provide an opinion about the relationship between the Veteran's exposure to ionizing radiation in service and his prostate cancer. Following review of the medical evidence of record, including opinions offered in support of the Veteran's claim and the cited studies, it was the opinion of the Under Secretary for Benefits that it was unlikely that the Veteran's prostate cancer disability could be attributed to ionizing radiation exposure in service. In a December 2003 statement to the Veteran, Dr. S.C.F. noted that the Veteran had requested information about his current condition, and stated, "I know you had been exposed to radiation in the Pacific Atoll. Clearly you have developed prostate cancer that did not respond to surgery, but is now being treated with aggressive radiation." The letter then went on to describe and discuss the side effects the Veteran had developed as a result of radiation therapy. In April 2004, VA requested that the Defense Threat Reduction Agency (DTRA) provide reconstructed dosimetry for the Veteran's participation in Operation GREENHOUSE. It was noted that the Veteran's special orders indicated he had been a Ground Radio Operator on temporary duty with his unit to Enewetak Atoll in 1951, and was present for all four shots of the operation. In March 2007, DTRA provided a Radiation Dose Assessment for the Veteran's participation in Operation GREENHOUSE. The report explained the new expedited process used to reconstruct dose estimates which involved establishing conservative theoretical maximum doses of radiation exposure. A "Scenario of Participation and Radiation Exposure," assembled in September 2006, along with the Veteran's comments on that scenario received later in September 2006, were carefully considered when reconstructing his dose estimates pursuant to this expedited process. The doses which the Veteran could have received during his participation in Operation GREENHOUSE were determined to be not more than: 18 rem for external gamma dose; 0.5 rem for external neutron dose; 4.5 rem for internal committed dose to the prostate (alpha); and 2 rem for internal committed dose to the prostate (beta + gamma). In May 2007, the Director of C&P Service referred the Veteran's claim to the VA Under Secretary for Health for an opinion regarding the relationship between the Veteran's radiation exposure and his adenocarcinoma of the prostate. In May 2007, VA's CPHEHO (Dr. L.R.D.) responded to the memorandum from VA's C&P Service. After noting the March 2007 radiation dose estimates from DTRA, he cited that the sensitivity of the prostate to radiation carcinogenesis appeared to be relatively low and not clearly established. He went on to state that the Interactive Radioepidemiological Program (IREP) of the National Institute of Occupational Safety and Health (NIOSH) was utilized to estimate the likelihood that exposure to ionizing radiation was responsible for the Veteran's prostate cancer. He reported that, utilizing the cancer model for all male genitalia, the computer software calculated a 99-percentile value for the probability of causation of 26.39%. Based on the foregoing, he opined that it was unlikely the Veteran's adenocarcinoma of the prostate could be attributed to his exposure to ionizing radiation in service. The report cited references and authorities for its data, findings, and conclusions. In a June 2007 opinion, the Director of C&P Service stated that the Under Secretary for Health had reviewed the Veteran's claims file to provide an opinion about the relationship between the Veteran's exposure to ionizing radiation in service and his prostate cancer. Following review of the medical evidence of record, including opinions offered in support of the Veteran's claim and the cited studies, it was the opinion of the Under Secretary for Benefits that there was no reasonable possibility that the Veteran's prostate cancer disability was the result of his exposure to ionizing radiation in service. On December 2007 VA genitourinary examination, the VA examiner opined that it was as least as likely as not that the Veteran's exposure to radiation resulted in prostate cancer. In a March 2009 addendum, the December 2007 VA genitourinary examiner noted that the claims file was entirely reviewed. He went on to note that, after reviewing the Department of VA Handbook 1301.01, it was recognized that exposure to ionizing radiation can lead to prostate cancer. He opined that therefore it was as least as likely as not that the Veteran's prostate cancer was secondary to ionizing radiation. In an April 2009 opinion, the Director of C&P Service noted that VA's CPHEHO reviewed the claims file on three occasions (November 1998, April 2001, and May 2007) and opined each time that it was unlikely that the Veteran's adenocarcinoma of the prostate could be attributed to exposure to ionizing radiation during service. He went on to note the opinion of the December 2007 VA genitourinary examiner in March 2009 (i.e., that it was as likely as not that the Veteran's prostate cancer was secondary to ionizing radiation), but observed that that VA examiner had not provided a rationale for the opinion or given a cause as to the most probable etiology of the Veteran's prostate cancer. He concluded that the opinion by VA's CPHEHO (a position that requires a physician Board Certified in Occupational Medicine and specialized in the health effects of exposure to ionizing radiation) was more credible than the opinion in March 2009 by the December 2007 VA examiner. Analysis The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. The evidence shows that the Veteran has been treated for adenocarcinoma of the prostate during the pendency of the instant claim. His STRs are silent for any disability of the prostate, and there is no evidence that prostate cancer was manifested to a compensable degree in the first year following his discharge from active duty. Consequently, service connection for adenocarcinoma of the prostate on the basis that such became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C.A. § 1112), is not warranted. Notably, the Veteran has not alleged (nor has he submitted competent evidence to show) that he has suffered from adenocarcinoma of the prostate continuously since service. See 38 C.F.R. § 3.303(b). Instead, the Veteran presents the theory of entitlement that he developed adenocarcinoma of the prostate as a result of exposure to ionizing radiation during his military service. The Veteran was exposed to ionizing radiation in service; he is a confirmed participant in Operation GREENHOUSE, conducted at the Pacific Proving Ground in 1951. See 38 C.F.R. § 3.309(d)(3)(ii)(A). He subsequently developed a radiogenic disease (i.e., prostate cancer); postservice private treatment records reflect that prostate cancer was diagnosed with in April 1997 and that the Veteran underwent a radical prostatectomy in June 1997. See 38 C.F.R. § 3.311(b)(2)(xxiii). The prostate cancer became manifest within the period specified by the regulation (i.e., five years or more after exposure); it was diagnosed almost 45 years after his discharge from service. See 38 C.F.R. § 3.311(b)(5)(iv). With the three requirements of 38 C.F.R. § 3.311(b) met, the DSWA provided a radiation dose estimate for the Veteran in August 1998 according to 38 C.F.R. § 3.311(a)(2)(i). The case was then forwarded to the Under Secretary for Benefits according to 38 C.F.R. § 3.311(c). An opinion was solicited from VA's CPHEHO (written for the Under Secretary for Health) in November 1998, who reviewed the available evidence of record (including the August 1998 radiation dose estimate and treatise information) and opined that it was unlikely that the Veteran's prostate cancer could be attributed to exposure to ionizing radiation in service. Thereafter, the case was returned to VA's Veterans Benefits Administration. In December 1998, the Director of C&P Service reviewed the available evidence of record and opined that there was no reasonable possibility that the Veteran's prostate cancer was the result of his exposure to ionizing radiation during service. In April 2001, VA's CPHEHO again reviewed the available evidence of record (including the December 2000 statement by Dr. J.G.S. and the literature cited by Dr. J.G.S. in his December 1997 and December 2000 statements) and again opined that it was unlikely that the Veteran's prostate cancer could be attributed to exposure to ionizing radiation in service. Thereafter, in May 2001, the Director of C&P Service reviewed the available evidence of record and opined that it was unlikely that the Veteran's prostate cancer disability could be attributed to ionizing radiation exposure in service. Following the Board's December 2003 remand, the DTRA provided a revised radiation dose estimate for the Veteran in March 2007 according to 38 C.F.R. § 3.311(a)(2)(i). The case was then forwarded to the Under Secretary for Benefits according to 38 C.F.R. § 3.311(c). An opinion was solicited from VA's CPHEHO (written for the Under Secretary for Health) in May 2007, who reviewed the available evidence of record (including the March 2007 radiation dose estimate, treatise information, and the IREP of the NIOSH's calculation of probability of causation) and opined that it was unlikely the Veteran's adenocarcinoma of the prostate could be attributed to his exposure to ionizing radiation in service. Thereafter, the case was returned to VA's Veterans Benefits Administration. In June 2007, the Director of C&P Service reviewed the available evidence of record and opined that there was no reasonable possibility that the Veteran's prostate cancer disability was the result of his exposure to ionizing radiation in service. In April 2009, the Director of C&P Service reviewed the available evidence of record, and concluded that the opinion by VA's CPHEHO was more probative than the opinion provided by the VA examiner, and opined that it was unlikely that the Veteran's prostate cancer disability could be attributed to ionizing radiation exposure in service. In light of the above, the Veteran cannot be granted service connection pursuant to 38 C.F.R. § 3.311. Moreover, prostate cancer is not a presumptive disease listed in 38 U.S.C.A. § 1112(c) or 38 C.F.R. § 3.309(d), so the Veteran cannot be granted service connection on that basis. Regarding a nexus between the Veteran's adenocarcinoma of the prostate and his exposure to ionizing radiation, the evidence of record contains various opinions by medical professionals both supporting and against the claim. In response to the observations/instructions in the June 2014 Joint Motion the Board will weigh the probative value of each of these opinions, fully addressing each of the favorable medical opinions in the record to include explanation why the Board finds them not persuasive. Of the medical opinions suggesting that the Veteran's prostate cancer is related to his radiation exposure in service, the Board finds that the following are entitled to lesser probative value, for the reasons stated: In June 1997, Dr. S.C.F. acknowledged the "suspicion" of the Veteran's radiation exposure in service, but also noted that "we will never know the cause of these cancers." This opinion merits little probative value because it is too speculative in nature. In December 1997, Dr. J.G.S. noted that "there were strong data to support a link between ionizing radiation exposure and the subsequent development of urinary tract malignancies," but the studies he cited involved "excessive exposure" and pilots who were "chronically exposed" to such radiation. This opinion merits little probative value because the rationale lacks any independent dose estimates or references to the Veteran's specific radiation doses in service. In January 1998 and December 2000, Dr. R.K.V. stated that "it is within the realm of possibility, and very probable that [the Veteran's] medical ailment [prostate cancer] is secondary to ionizing radiation," further noting that he was especially suspicious of this etiology in the Veteran because he lacked a family history of prostate cancer. This opinion merits little probative value because the rationale does not contemplate any independent dose estimates or references to the Veteran's specific radiation doses in service. In January 1998 (in two statements), Dr. S.E.S. opined that it was "certainly within the realm of possibility" that the Veteran's radiation exposure "may have triggered his prostate cancer" and that his radiation exposure "certainly increased his cancer risk for...perhaps prostate malignancy." This opinion merits little probative value because it is too speculative in nature. In February 1998, Dr. S.C.F. again opined that the Veteran's prostate cancer "may have been very well linked to his exposure [to radiation] during his service career in the South Pacific," and cited life-span studies of A-bomb survivors. This opinion merits little probative value because it is too speculative in nature. In December 2007, a VA genitourinary examiner opined that it was as least as likely as not that the Veteran's exposure to radiation resulted in prostate cancer. In a March 2009 addendum, the same VA examiner noted that the entire record had been reviewed, and again opined that it was as least as likely as not that the Veteran's prostate cancer was secondary to ionizing radiation, citing to the Department of VA Handbook 1301.01 which recognizes that exposure to ionizing radiation can lead to prostate cancer. This opinion merits probative value because the rationale cites to Department guidelines which raise only a possibility of a nexus and suggest the need for the further development (that has been done in this case); it lacks any consideration of independent dose estimates or references to the Veteran's specific radiation doses in service. Of the medical opinions suggesting that the Veteran's prostate cancer is related to his radiation exposure in service, the Board finds that the following is entitled to higher probative value, for the reasons outlined below: In December 2000, Dr. J.G.S. reviewed the entire record and opined that the data (which supported a link between ionizing radiation exposure and the subsequent development of urinary tract malignancies) strongly supported a relationship between radiation exposure and the development of carcinoma of the prostate and were relevant to the Veteran's claim. The Board finds that this opinion is entitled to high probative value because it is not speculative in nature, it is supported by adequate rationale (specifically citing to pertinent authorities as well as the Veteran's specific radiation doses in service), and was rendered with consideration of the entire record. Of the medical opinions indicating that the Veteran's prostate cancer is not related to his radiation exposure in service, the Board finds that the following are entitled to higher probative value, for the reasons outlined below: In November 1998, Dr. S.H.M. (VA's CPHEHO) reviewed the entire record and opined that it was unlikely the Veteran's prostate cancer could be attributed to his exposure to ionizing radiation in service. This opinion merits high probative value because it is not speculative in nature, is supported by adequate rationale (specifically citing to pertinent authorities as well as the Veteran's specific radiation doses in service), and was provided with consideration of the entire record. In April 2001, Dr. S.H.M. (VA's CPHEHO) again reviewed the entire record, including Dr. J.G.S.'s December 2000 statement and the studies cited therein. After contrasting the studies cited by Dr. J.G.S. with other epidemiological studies which found either no increases or non-statistically significant increases of prostate cancer, she opined that it was unlikely that the Veteran's prostate cancer could be attributed to exposure to ionizing radiation in service. This opinion is entitled to high probative value because it is not speculative in nature, is supported by adequate rationale (specifically citing to pertinent authorities as well as the Veteran's specific radiation doses in service), and was rendered with consideration of the entire record. In May 2007, Dr. L.R.D. (VA's CPHEHO) reviewed the entire record and opined that it was unlikely the Veteran's adenocarcinoma of the prostate could be attributed to his exposure to ionizing radiation in service. The Board finds that this opinion is entitled to high probative value because it is not speculative in nature, it is supported by adequate rationale (specifically citing to pertinent authorities as well as the Veteran's specific radiation doses in service), and it was rendered with consideration of the entire record. Comparing only the medical opinions identified above as being entitled to significant/higher probative value, the Board finds that the December 2000 opinion of Dr. J.G.S. is equal in probative value to the November 1998 opinion of VA's CPHEHO, but is entitled to less probative value than the April 2001 and May 2007 opinions of VA's CPHEHO. To support this conclusion, the Board notes that the April 2001 CPHEHO opinion contrasted the studies cited in Dr. J.G.S.'s December 2000 opinion with other epidemiological studies with conclusions to the contrary, and that the April 2001 and May 2007 CPHEHO opinions both took into account the Veteran's specific radiation doses in service as estimated in both August 1998 and March 2007 (while the March 2007 data were not available (in existence) when Dr. J.G.S. rendered his December 2000 opinion). In light of the above, the Board finds that the preponderance of the evidence is against a finding of a nexus between the Veteran's adenocarcinoma of the prostate and his exposure to ionizing radiation. See Combee, 34 F.3d at 1039, 1042. The Veteran is competent to describe any discernible symptoms affecting his prostate without any specialized knowledge or training. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). However, his statement relating his adenocarcinoma of the prostate to ionizing radiation exposure in service is not competent evidence, as he is a layperson, and lacks the training to opine regarding medical causation; whether a disease/condition is related to ionizing radiation exposure is a complex medical question, beyond the scope of resolution by lay observation. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans' Court). In light of the foregoing, the Board concludes that the preponderance of the evidence is against this claim. Accordingly, it must be denied. ORDER The appeal seeking service connection for adenocarcinoma of the prostate, to include as due to exposure to ionizing radiation, is denied. REMAND The Veteran contends that he developed degenerative joint disorders (affecting his feet, ankles, knees, hips, back, fingers, hands, wrists, elbows, and shoulders) as a result of exposure to ionizing radiation during his military service. The Board's August 2013 remand instructed the AOJ to arrange for an orthopedic examination of the Veteran to ascertain the nature and likely etiology of any current degenerative joint disorders affecting the feet, ankles, knees, hips, back, fingers, hands, wrists, elbows, and shoulders. For each diagnosed disability and opinion rendered for such, the examiner was to specifically consider and address the Veteran's confirmed exposure to ionizing radiation in service; the July 2009 revised dose estimate to the bones; the January 2010 opinions by the VA Director of Radiation and Physical Exposures and the Director of C&P Service; and, for the right elbow, the August 1952 STR noting a month-old right elbow injury. In addition, the examiner was required to explain the rationale for all opinions. On June 2014 VA orthopedic examination, the diagnosis was degenerative arthritis of both feet (first diagnosed in the 1970s); degenerative joint disease (DJD) of both ankles (first diagnosed in the 1970s); DJD of both knees (first diagnosed in the 1960s); DJD of both hips (first diagnosed in the 1960s); degenerative arthritis of the spine (first diagnosed in the 1970s); DJD of both hands, including the fingers (first diagnosed in the 1960s); DJD of both wrists (first diagnosed in the 1960s); DJD of both elbows (first diagnosed in the 1960s); and DJD of both shoulders (first diagnosed in the 1960s). For each diagnosed disability, the examiner provided the following opinion verbatim: "The Veteran's [claimed condition] is less likely as not incurred in or aggravated by the Veteran's active service. Rationale: This opinion is formed after interview and exam of the Veteran, review of the c[laims] file and medical records, consideration of the Veteran's confirmed exposure to ionizing radiation in service, the July 2009 revised dose estimate to the bones, the January 2010 opinions by the VA Director of Radiation and Physical Exposures and [t]he director of the C&P Service, and to my knowledge, no references in the peer-reviewed medical literature have associated arthritis with exposure to ionizing radiation." [For the right elbow, the examiner also noted the pertinent STR.] However, the Board finds that the rationale for such opinion is inadequate, as it consists of only a recitation of the evidence required for consideration and does not provide any explanation as to how such evidence was applied or considered by the examiner when rendering the opinion for each diagnosed disability. Therefore, an addendum medical opinion for each disability must be obtained on remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Accordingly, the case is REMANDED for the following: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should return the record to the VA examiner who conducted the June 2014 VA orthopedic examination for an addendum opinion. The examiner must review the entire record (to include this remand) and provide opinions that respond to the following: Please identify the most likely etiology for each disability entity of the feet, ankles, knees, hips, back, fingers, hands, wrists, elbows, and shoulders diagnosed. Specifically, is it at least as likely as not (a 50% or better probability) that such was incurred or aggravated during the Veteran's active service? The examiner must specifically consider and address the Veteran's confirmed exposure to ionizing radiation in service (and, for the right elbow, the August 1952 STR noting a month-old right elbow injury). The examiner must explain the rationale for all opinions, citing to relevant STRs, supporting factual data, and medical literature, as appropriate (including the July 2009 revised dose estimate to the bones, the January 2010 opinion by the VA Director of Radiation and Physical Exposures, and the January 2010 opinion by the Director of C&P Service). If the VA examiner who conducted the June 2014 examination is unavailable, the AOJ should arrange for the entire record to be reviewed by another appropriate medical provider who should provide the opinions sought. If further examination of the Veteran is deemed necessary to provide any requested opinion, such examination should be scheduled. 2. The AOJ should ensure that all development sought is completed, arrange for any further development suggested by any additional evidence received, and then review the record and readjudicate the claim remaining on appeal. If the benefit sought remains denied, the AOJ should issue an appropriate SSOC and afford the Veteran and his attorney the opportunity to respond. The case should then be returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter 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. 2014). ______________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs