Citation Nr: 1636078	
Decision Date: 09/15/16    Archive Date: 09/27/16

DOCKET NO.  14-23 048	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Paul, Minnesota


THE ISSUE

Entitlement to service connection for prostate cancer.


REPRESENTATION

Appellant represented by:	The American Legion


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

H. Yoo, Counsel


INTRODUCTION

The Veteran served on active duty from March 1951 to March 1955. 

This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2013 by the St. Paul, Minnesota, Regional Office (RO) of the Department of Veterans Affairs (VA).

In March 2016, in accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, the Board requested a medical expert opinion from the Veterans Health Administration (VHA) regarding the claim.  In May 2016, the Board received the requested opinion.

This appeal contains documents in the Veteran's electronic Virtual VA file and Veterans Benefits Management System file.  All records have been reviewed in conjunction with the adjudication of the claim currently on appeal.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015).  38 U.S.C.A. § 7107(a)(2) (West 2014).


FINDING OF FACT

There has been no demonstration by competent medical, or competent and credible lay, evidence of record that the Veteran's prostate cancer is related to active duty, to include exposure to ionizing radiation.


CONCLUSION OF LAW

The criteria for service connection for prostate cancer, have not been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2015).


REASONS AND BASES FOR FINDING AND CONCLUSION

I. The Veterans Claims Assistance Act of 2000 (VCAA)

VA has a duty to notify and assist veterans in substantiating a claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). 

Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide in accordance with 38 C.F.R. § 3.159 (b)(1).  This notice must be provided prior to an initial unfavorable decision on a claim by the RO.  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). 

In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded.  Id. at 486. 

VA's duty to notify was satisfied by a letter dated March 2013.  See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).

Next, VA has a duty to assist the Veteran in the development of the claim.  This duty includes assisting him in the procurement of service treatment records and pertinent post-treatment records, and providing an examination when necessary.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 

The Board finds that all necessary development has been accomplished as to the issues decided herein, and therefore appellate review may proceed without prejudice to the Veteran.  See Bernard v. Brown, 4 Vet. App. 384 (1993).  VA incorporated the Veteran's in-service treatment records into his claims file.  In addition, post-service treatment records from the Veteran's private doctors have been incorporated into the claims file.

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.  The record indicates that the Veteran was afforded VA examinations in July 2013 and December 2013.  These opinions involved a thorough review of the claims file and the opinions were was supported by a sufficient rationale.  Therefore, the Board finds that the reports are 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 VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim decided herein.

In June 2013 the Board obtained a VHA opinion with respect to the Veteran's claim.  The VHA report reflects that the examiner reviewed the Veteran's claims folder, reviewed his past medical history, documented his medical conditions, and rendered an appropriate opinion consistent with the remainder of the evidence of record.  The Board therefore concludes that the VHA opinion is adequate for evaluation purposes.  See 38 C.F.R. § 4.2 (2015); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate).

As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless.  See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007).  Importantly, the Board notes that the Veteran is represented in this appeal.  See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006).  The Veteran has submitted argument and evidence in support of the appeal.  Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim decided herein such that the essential fairness of the adjudication is not affected.

II. The Merits of the Claim

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; 38 C.F.R. § 3.303.  Disorders diagnosed after discharge will 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).

In order to establish service connection on a direct basis, the record must contain: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 

Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 

While prostate cancer is not a specifically listed chronic disease, it is included under the broader listed category of malignant tumors, and therefore service connection can be established via continuity of symptomatology.  38 C.F.R. § 3.303(b), 3.309(a); Walker, 708 F.3d 1331.

Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods.  Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997).  First, there are certain diseases for which presumptive service connection may be granted if they are manifested in a veteran who participated in a radiation-risk activity.  38 U.S.C.A. § 1112(c); 38 C.F.R. § 3.309(d).  Second, "radiogenic diseases" may be service-connected pursuant to 38 C.F.R. § 3.311.  Third, service connection may be granted under 38 C.F.R. § 3.303(d) when it is established that the disease diagnosed after discharge is the result of exposure to ionizing radiation during active service.  See Combee v. Brown, 34 F.3d 1039   (Fed. Cir. 1994).

Under Combee, VA must not only determine whether a veteran had a disability recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether the disability was otherwise the result of active service.  In other words, the fact that the requirements of a presumptive regulation are not met does not in and of itself preclude a claimant from establishing service connection by way of proof of actual direct causation.

A "radiation-exposed veteran" is one who, while serving on active duty or on active duty for training or inactive duty for training, participated in a radiation-risk activity.  "Radiation-risk activity" includes "onsite participation" in a test involving the atmospheric detonation of a nuclear device by the United States or a foreign nation.  38 U.S.C.A. § 1112(c)(3)(B)(i); 38 C.F.R. § 3.309(d)(3).  The occupation of Hiroshima, Japan or Nagasaki, Japan, by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946.  38 C.F.R. § 3.309(b)(i), (ii).

If a claimant does not qualify as a "radiation-exposed veteran" under 38 C.F.R. § 3.309(d)(3) and/or does not suffer from one of the presumptive conditions listed in 38 C.F.R. § 3.309(d)(2), the veteran may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if the veteran suffers from a radiogenic disease and claims exposure to ionizing radiation in service. 

Under 38 C.F.R. § 3.311, "radiogenic disease" means a disease that may be induced by ionizing radiation and shall include the following: (i) All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) Thyroid cancer; (iii) Breast cancer; (iv) Lung cancer; (v) Bone cancer; (vi) Liver cancer; (vii) Skin cancer; (viii) Esophageal cancer; (ix) Stomach cancer; (x) Colon cancer; (xi) Pancreatic cancer; (xii) Kidney cancer; (xiii) Urinary bladder cancer; (xiv) Salivary gland cancer; (xv) Multiple myeloma; (xvi) Posterior subcapsular cataracts; (xvii) Non-malignant thyroid nodular disease; (xviii) Ovarian cancer; (xix) Parathyroid adenoma; (xx) Tumors of the brain and central nervous system; (xxi) Cancer of the rectum; (xxii) Lymphomas other than Hodgkin's disease; (xxiii) Prostate cancer; and (xxiv) Any other cancer.  38 C.F.R. § 3.311(b)(2).  Section 3.311(b)(5) requires that colon cancer become manifest 5 years or more after exposure.  38 C.F.R. § 3.311(b)(5).

Under the special development procedures in § 3.311(a), dose data will be requested from the Department of Defense in claims based upon participation in atmospheric nuclear testing, and claims based upon participation in the American occupation of Hiroshima or Nagasaki, Japan, prior to July 1, 1946. 38 C.F.R. § 3.311(a)(2).  In all other claims, 38 C.F.R. § 3.311(a) requires that a request be made for any available records concerning the veteran's exposure to radiation.  These records normally include but may not be limited to the veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service treatment records, and other records which may contain information pertaining to the veteran's radiation dose in service.  All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies.  38 C.F.R. § 3.311(a)(2)(iii).  As the Veteran has essentially contented that his radiation exposure was related to atmospheric nuclear testing, development under 38 C.F.R. § 3.311(a)(2)(iii) is not necessary. 

In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's treatment records, and all pertinent medical and lay evidence.  38 U.S.C.A. § 1154 (a) (West 2014).

The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis.  Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006).

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 the evidence submitted by the Veteran or on his behalf.  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 Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein.  Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant).

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 appellant.  Equal weight is not always accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value.  When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

The Veteran served on active duty from March 1951 to March 1955.  He was diagnosed with prostate cancer in November 2004 and it is his contention that this disorder is related to his participation in Operation CASTLE, a series of atmospheric nuclear detonations that were conducted at the Pacific Proving Grounds from March to May 1954.  The Veteran was initially exposed to ionizing radiation at age 23 and prostate cancer was diagnosed 50 years after initial exposure.  The Veteran has never been a smoker and has not been exposed in his post-service employment.  The Veteran does not have any family history of cancer or leukemia.  

The Board notes that VA received a letter from the Defense Threat Reduction Agency (DTRA) in April 2015, establishing that the Veteran was a confirmed participant in Operation CASTLE, a U.S. atmospheric nuclear test series conducted at the Pacific Proving Ground in 1954.  The doses which the Veteran could have received during his participation in Operation CASTLE were not more than: 

• External gamma dose: 18 rem
• External neutron dose: 0.5 rem
• Internal committed dose to the prostate (alpha): 4.5 rem
• Internal committed dose to the prostate (beta plus gamma): 2 rem

Thus, the central question is whether it is at least as likely as not that the Veteran's prostate cancer is attributable to the radiation exposure he received.  In this regard, the Board notes that there are conflicting medical nexus opinions of record.

According to a determination by the Director of the Post-9/11 Environmental Health Program, it was opined that it was unlikely that the Veteran's prostate cancer can be attributed to ionizing radiation exposure while in military service.  He explained that the Interactive Radio Epidemiological Program of the National Institute for Occupational Safety and Health (NIOSH) was used to estimate the likelihood that exposure to ionizing radiation was responsible for the Veteran's prostate cancer.  Therefore, using the data provided to the DTRA, the program calculated a 99th percentile value for the total probability of causation of 22.71 percent.

However, in November 2015 Dr. C.N. Bash, a private Neuro-Radiologist, stated "[i]t is my opinion considering every possible sound medical etiology/principle, to at least the 90 [percent] level of probability that his current prostate cancer problems are due to his experience with radiation in service..."  Dr. Bash explained that the stochastic risk for radiation can cause cancer in very low doses and therefore, it is not a threshold.  Dr. Bash explained that the medical literature supports a link between radiation exposure and cancer of the solid organs as the prostate is a solid organ.   

The Board finds, however, that Dr. Bash's November 2015 opinion is internally inconsistent.  Dr. Bash attached the article "Ionizing Radiation and Cancer Risk: Evidence from Epidemiology" which stated, "[c]hronic lymphocytic leukemia, Hodgkin's disease, and cancers of the pancreas, prostate, testis and cervix have rarely been linked to radiation exposure" but in the Veteran's case it was a 90 percent level of probability that the Veteran's prostate cancer was due to his exposure to radiation in service, according to Dr. Bash.  It is unclear how Dr. Bash established this probability. 

Therefore, given the conflicting nexus opinions and the inconsistencies in Dr. Bash's opinion, the Board requested from a radiation physicist or therapeutic radiologist that, following review of the Veteran's claims folder, including all pertinent medical records, and based on that review an opinion is rendered, accompanied by a rationale, for the following question: 

Is it at least as likely as not (a 50 percent or better probability) that the Veteran's prostate cancer is causally or etiologically related to his documented exposure to ionizing radiation or another event or incident of his period of active service?

The rationale provided for the opinion should include citation to supporting factual data and medical literature, if indicated.  In rendering the opinion, the examiner is requested to discuss the significance of the Veteran's dose estimate of ionizing radiation exposure due to his participation in Operation CASTLE, a U.S. atmospheric nuclear test series conducted at the Pacific Proving Ground in 1954.  The examiner is also asked to address and resolve any inconsistencies in or between the determinations of the Director, Post-9/11 Environmental Health Program, and Dr. C.N. Bash.

Subsequently, Dr. A. S., provided the requested medical opinion in May 2016.  Dr. S.'s credentials include Chief of Radiation Oncology at the West Los Angeles Medical Center who has treated hundreds of  prostate cancer patients with radiology for the past thirty years; a Board certified radiologist by the American Board of Radiology; a senior member of the American Society of Therapeutic Radiology; and a member of the North America Radiological Society.  Dr. S. noted that he considered the Veteran's gender; family history; age at the time of radiation exposure; time lapse between exposure and onset of the disease (50 years in this case); the relative sensitivity of the involved issues (the prostate is not considered to be a very sensitive organ) to induction of cancer by ionizing radiation; extent of exposure to other carcinogens outside of service that may have contributed to his cancer; the type of radiation (gamma, neutron, alpha, and beta), rate, duration; and the estimated distance from the center of the blast (more than 2 km).  Dr. S. stated the Veteran's pathology report of prostatectomy specimen indicate that he has developed adenocarcinoma of the prostate with pathological stage of pT2b, Gleason score of 9, and tumor involving 20 percent of the tissue sample that involved only the right lobe of prostate.  The seminal vesicle and nodes were negative for tumor.  Furthermore, Dr. S. stated he has reviewed the arguments against and in favor of radiation causing the Veteran's cancer.  He stated he agreed in principle with the NOISH determination that the Veteran's cancer is not caused only by his previous radiation exposure.  However, Dr. S. did not agree that the stochastic general principle argument by Dr. Bash was highly applicable to this case as this principal applied to all body organs.  Overall, he opined that "it is not likely that the Veteran's prostate cancer is caused by or related etiologically to exposure to ionizing radiation during period of active service (a 50% better probability)."   

Dr. S. cited to the medical treatise entitled, "Effects of Radiation on the Incidence of Prostate Cancer Among Nagasaki Atomic Bomb Survivors,"  Cancer Sci. 2013 Oct;104(10):1368-71. doi: 10.1111/cas.12234. Epub 2013 Aug 12, which estimated the health risks from exposure to relatively low levels of ionizing radiation and provided information about solid tumor incidence and relative risk of at least fifteen different cancers among 120,00 survivors of the atomic bombings in Hiroshima and Nagasaki, Japan in 1945.  Ultimately, Dr. S. stated that according to this study "incidence of prostate cancer has not increased relative to the other cancers with P value of 0.42 that is not statistically significant.  This study support[s] the idea that cancer of the prostate has multifactorial causes and radiation exposure alone is not the only factor in causing prostate cancer." 

Dr. S. stated that while studies do indicate a significant relationship between the atomic bomb excessive radiation and prostate cancer in heavily radiated patients that reside in proximity of the explosion, less than 2 km.  However, "[t]his may not apply to this Veteran since he was not very close to the [b]last center.  By one estimate, the first Atomic test (Trinity) he could be located at 19 km from the center of [the] blast therefore, the dose he received is not considered to be excessive and causing cancer of [the] prostate."  Furthermore, according to National Research Council's Committee on Biological Effects of Exposure to Ionizing Radiations the "sensitivity of the prostate to the induction of cancer by irradiation appears to be comparatively low." 

According to a study to determine whether veterans who receive the highest gamma radiation doses (n=1010) have experienced increased cancer mortality compared with a group of Navy veteran who received a minimal radiation dose as participants of HARDTACK I (n=2870), "[t]he lack of statistically significant excesses in death from many of the known radiogenic cancers (including prostate cancer) suggests that the observed excess mortality may be the result of many factors, of which radiation exposure was only one.  In case of prostate cancer there are multiple other causative factors involved that cannot be easily ruled out." 

In addition, Dr. S. noted the article "Ionizing Radiation and Cancer Risk: Evidence from Epidemiology," Ron, E. Ped Radiol (2002) 32: 232. doi:10.1007/s00247-002-0672-0, was cited by Dr. Bash as evidence that prostate cancer [radiation] can be the cause of prostate cancer."  However, Dr. S. disagreed and explained "it has been stated in the same article that chronic lymphocytic leukemia, Hodgkin's disease, and cancers of the pancreas, prostate, testis and cervical have rarely been linked to radiation exposure.  This article states clearly that radiation does not act entirely in isolation 'except in very large doses' and can interact with other carcinogens.  Therefore, radiation alone cannot be incriminated for production of cancer of the prostate."  Dr. S. further stated "[t]his is specifically true for this Veteran due to relatively small dose and the fact that some part of radiation received by Veteran due to relatively small dose and the fact that some part of radiation received by [the] Veteran is in alpha and beta form with limited penetration to reach the prostate.  One should also ask why only the right lobe of prostate is harboring cancer while the entire prostate was exposure to radiation."

Finally, according to the article, "Cancer incidence in atomic bomb survivors. Part II: Solid tumors, 1958-1987," Radiat Res. 1994 Feb;137(2 Suppl):S17-67, comprehensive data on the incidence of solid cancer and risk estimates for the atomic bomb survivors in the extended life span study indicate that among 79,972 individuals, 8613 first primary solid cancers were diagnosed between 1958 and 1987, where "[m]any solid cancer including colon, bladder, lung, [t]hyroid, [b]reast, liver, skin and ovary was mentioned in the report but prostate cancer is not among them."  

Therefore, based on a review of the medical evidence of record to include etiological opinions and the above medical treatises, Dr. S. determined it is not likely that the Veteran's prostate cancer is caused or related etiologically to exposure to ionizing radiation during his period of active service.

Given the totality of the evidence, the Veteran's claim must be denied.

The Board recognizes there is positive and negative nexus opinion evidence within the record.  However, the Court has held that in comparing positive and negative evidence, the Board may favor the opinion of one competent medical professional over that of another, as long as an adequate statement of reasons and bases is provided.  See Owens v. Brown, 7 Vet. App. 429, 433 (1995).  With regard to medical opinions, the credibility and weight to be attached to a medical opinion are within the Board's province as finder of fact.  Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).  Greater weight may be placed on one opinion over another depending on factors such as reasoning employed and whether the examiner was informed of the relevant facts.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).  Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion.  Prejean v. West, 13 Vet. App. 444, 448-49 (2000).

While Dr. Bash does provide a positive nexus opinion, the Board finds that the VHA opinion from Dr. S. is more probative.  The VHA opinion offered detailed explanations of the rationale for the opinions that incorporate both the facts of the Veteran's case and the pertinent medical principles.  Given Dr. S.'s access to the claims folder and the thoroughness and detail of his opinions, the Board finds his opinions to be highly probative to determining whether service connection for this claim is warranted.  Dr. Bash's opinion is of little probative value due to inconsistencies noted above.  Id. at 300-01.  

Dr. S.'s opinion is most probative as factual details discussed in the opinion demonstrated that he was informed of the Veteran's medical history, and his opinion was thoroughly articulated and supported by a reasoned analysis.  Not only did Dr. S. address the merits of each medical treatise cited but he also provided a comprehensive analysis of the underlying source material relied upon by the articles.  Moreover, he offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two.  See Nieves-Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007

The Board acknowledges the Veteran's contentions that his prostate cancer is related to ionizing radiation exposure during service.  The Veteran is considered competent to report the observable manifestations of his claimed disability.  See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony iterating knowledge and personal observations of witness are competent to prove that claimant exhibited certain symptoms at particular time following service).  However, the Veteran is not competent to opine on the diagnosis or etiology of his disability.  Where a determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required.  See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993).  In this case, the etiology of current prostate cancer is a complex medical question that is not within the competence of a layperson.  See Kahana v. Shinseki, 24 Vet. App. 428 (2011).

In arriving at this conclusion, the Board has considered the doctrine of reasonable doubt, but finds that the preponderance of the evidence is against a finding of entitlement to service connection for prostate cancer; the claim is therefore denied.  See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102, 3.312; Gilbert, 1 Vet. App. at 58 (if the Board rules against a veteran in a case where there are "two permissible views" of the evidence, the Board must provide an "adequate statement of [its] reasons or bases" in support of its determination that the veteran is not entitled to the benefit of the doubt) (internal quotations omitted).


ORDER

Entitlement to service connection for prostate cancer is denied.



____________________________________________
BARBARA B. COPELAND
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs