Citation Nr: 1802927 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 13-09 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to a rating in excess of 20 percent for residuals of prostate cancer with erectile dysfunction. 2. Entitlement to service connection for a bone disorder, to include as secondary to service-connected residuals of prostate cancer with erectile dysfunction. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected residuals of prostate cancer with erectile dysfunction. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Christopher M. Collins, Associate Counsel INTRODUCTION The Veteran had active military service from November 1963 to November 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2012 and September 2013 rating decision of the VA Regional Office (RO) in San Diego, California. This case was last before the Board in February 2017, whereupon it was remanded to the RO, via the Appeals Management Center (AMC) located in Washington, D.C., for further development of the record. Following the issuance of a July 2017 supplemental statement of the case, the matter was returned to the Board for its adjudication. In September 2016 the Veteran and his wife testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) sitting in Washington, D.C. A transcript of the hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. During the entire pendency of the appeal, the Veteran's prostate cancer has been manifested by no more than urinary frequency with a daytime voiding interval between one and two hours, or awakening to void three to four times per night, and erectile dysfunction with no penile deformity; the prostate cancer is not manifested by renal dysfunction or a urinary tract infection. 2. The competent medical evidence does not demonstrate that the current left hip osteopenia is attributable to the Veteran's active service or any incident of service, to include treatment for the service-connected prostate cancer. 3. The competent medical evidence does not demonstrate that the current left hip osteopenia is attributable to the Veteran's active service or any incident of service, to include treatment for the service-connected prostate cancer. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for residuals of prostate cancer with erectile dysfunction have not been met. 38 U.S.C §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.115a, 4.115b, Diagnostic Codes 7522, 7528 (2017). 2. The criteria for service connection for a bone disorder have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). 3. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017); Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As a preliminary matter, the Board has reviewed the claims file and finds that there exist no deficiencies in VA's duties to notify and assist that would be prejudicial and require corrective action prior to a final Board determination. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159; see also Bryant v. Shinseki, 23 Vet. App. 488 (2010) (regarding the duties of a hearing officer); Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (corrective action to cure a 38 C.F.R. § 3.159(b) notice deficiency); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004) (timing of notification). The Board also notes that, to the full extent possible, VA complied with all prior remand instruction requests, and there exist no deficiencies in VA's duties to notify and assist in that regard. See Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order); but see D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required). Increased Rating for Residuals of Prostate Cancer with Erectile Dysfunction Service connection for residuals of prostate cancer was granted in a November 2007 rating decision and was assigned a noncompensable evaluation effective May 25, 2007. Thereafter, the RO in a May 2008 rating decision increased the evaluation of the residuals of prostate cancer to 20 percent effective December 18, 2007, and added a noncompensable evaluation for erectile dysfunction as a distinct condition residual to the prostate cancer. The Veteran filed a claim for an increased rating of the prostate cancer residuals with erectile dysfunction in April 2012, which was denied in an August 2012 rating decision. The appeal of that denial is currently before the Board. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See generally Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In the August 2012 rating decision in which the 20 percent evaluation was continued, the RO listed the applicable Diagnostic Code as 7522-7528. Hyphenated Diagnostic Codes are utilized when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. The use of Diagnostic Code 7522, which corresponds to the loss of erectile power with penis deformity, reflects that the Veteran's erectile dysfunction was the most prominent residual condition associated with the prostate cancer and its treatment. Diagnostic Code 7528 provides for a single 100 percent disability rating for active prostate cancer. In the absence of evidence tending to show a malignant neoplasm, the prostate cancer is to be rated on the basis of residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528 (2017). The hyphenated inclusion of Diagnostic Code 7528 reinforces that the erectile dysfunction is to be considered a residual condition of the prostate cancer and its treatment. Diagnostic Code 7522 provides for a single 20 percent rating for evidence of loss of erectile power. Despite listing 7522 as the prominent Diagnostic Code for evaluating the residuals of the prostate cancer and its treatment, however, a review of the RO's initial August 2012 rating decision and subsequent adjudicatory actions illustrates that the 20 percent increased was awarded on the basis of associated voiding dysfunction and that in fact the RO had found that the erectile dysfunction warranted a noncompensable rating. Although not listed on the RO's rating codesheet, it is clear that the RO applied 38 C.F.R. § 4.115a in evaluating the voiding dysfunction, which provides for different ratings under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. 38 C.F.R. § 4.115a. Evaluation under urine leakage involves ratings ranging from 20 to 60 percent and contemplates continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day, a 60 percent evaluation is warranted. When there is leakage requiring the wearing of absorbent materials which must be changed two to four times per day, a 40 percent disability rating is warranted. A 20 percent rating contemplates leakage requiring the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a. Urinary frequency encompasses ratings ranging from 10 to 40 percent. A 40 percent rating contemplates a daytime voiding interval less than one hour, or awakening to void five or more times per night. A 20 percent rating contemplates daytime voiding interval between one and two hours, or awakening to void three to four times per night. A 10 percent rating contemplates daytime voiding interval between two and three hours, or awakening to void two times per night. 38 C.F.R. § 4.115a. Finally, obstructed voiding entails ratings ranging from noncompensable to 30 percent. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc's); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc's per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every two to three months. A noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. 38 C.F.R. § 4.115a. Urinary tract infections requiring drug therapy, one to two hospitalizations per year and/or requiring intermittent intensive management warrant a 10 percent evaluation. A 30 percent rating is warranted for recurrent symptomatic infections requiring drainage/frequent hospitalization (greater than two times per year), and/or requiring continuous intensive management. Where urinary tract infections result in poor renal function, the disability is to be evaluated as poor renal function. 38 C.F.R. § 4.115a. Renal dysfunction manifested by constant or recurring albumin with hyaline and granular casts or red blood cells, or transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101 warrants a 30 percent evaluation. Renal dysfunction resulting in albuminuria with some edema, or definite decrease in kidney function, or hypertension at least 40 percent disabling under diagnostic code 7101 warrants a 60 percent evaluation. Renal dysfunction manifested by persistent edema and albuminuria with BUN 40 to 80mg%, or creatinine 4 to 8mg%, or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion, warrants an 80 percent evaluation. Finally, renal dysfunction that requires regular dialysis, or precludes more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80mg%; or creatinine more than 8mg%; or markedly decreased function of kidney or other organ systems, especially cardiovascular, warrants a 100 percent evaluation. 38 C.F.R. § 4.115a. The evidence associated with the claims file does not reflect that the Veteran has experienced renal dysfunction or recent urinary tract infections. Accordingly, the Board, consistent with the RO's evaluation, will review only the criteria applicable to rating voiding dysfunction in determining whether an increased rating is warranted at any point during the pendency of the appeal. The Veteran was afforded a VA examination in connection with his claim for an increased rating in July 2012. He reported that he was diagnosed with and had radiation therapy for prostate cancer in 2003, and that the cancer had been in remission ever since that time. He also stated that he had voiding dysfunction, but acknowledged that he did not experience urine leakage or require the use of an appliance. He did, however, endorse experiencing daytime voiding intervals between two and three hours and nighttime awakening to void three or four times a night. He dismissed experiencing any obstructed voiding or history of urinary tract or kidney infection. He also detailed having developed erectile dysfunction after radiation therapy which had not responded to treatment. The examiner reported no other residuals of the prostate cancer. A disability benefits questionnaire was administered to evaluate the severity of the Veteran's prostate cancer residuals in June 2014. He reported experiencing burning during urination, and endorsed experiencing daytime voiding intervals between two and three hours and nighttime awakening to void three or four times a night. He also detailed experiencing obstructed voiding, with symptoms of hesitancy, slow stream, and decreased force of stream, all of marked severity. According to the Veteran, he had been prescribed a variety of applications to relieve his symptoms including a pump, pills and injections, none of which worked to alleviate those symptoms. The Veteran again denied any history of urinary tract infection but did detail a history of erectile dysfunction. The Veteran was afforded a new VA examination to evaluate the severity of his prostate cancer residuals in March 2017. He reported that he could only hold his bladder for 30 minutes, but denied any leakage or obstruction and acknowledged that his urinary stream was good. The examiner evaluated the voiding dysfunction as resulting in daytime intervals of between one and two hours. It was the examiner's opinion that the urinary dysfunction was only mild in severity. On an associated reproductive system examination also administered in March 2017 the examiner noted that the Veteran's penis was normal upon physical examination. A review of available postservice medical records, both from VA providers and private medical treatment providers, does not reflect that the Veteran exhibited symptoms of voiding dysfunction that were more severe than those reported on the various examinations he has had during the appeal period. Those records show that the Veteran has had continued treatment for voiding and erectile dysfunction and that his cancer has remained in remission. Upon review of the record, the Board finds that the disability picture for the Veteran's residuals of prostate cancer with erectile dysfunction does not warrant a rating in excess of 20 percent at any point during the pendency of the current appeal. On all three examinations the Veteran reported experiencing nighttime urinary frequency requiring that he wake up to void at least three times a night, which corresponds to the currently assigned 20 percent rating. The Veteran also reported daytime urinary frequency, but the frequency was never evaluated as resulting in intervals of less than one hour, which would be required for a 40 percent rating. The Veteran was also never evaluated as requiring the use of an application or absorbent materials, and although he endorsed experiencing some obstructive symptomatology, he never reported that his retention required intermittent or continuous catherization, as would be necessary for a 30 percent rating. Accordingly, on the basis of the voiding dysfunction alone, the Veteran's symptomatology did not warrant more than the currently assigned 20 percent rating. Furthermore, as the record does not reflect that the Veteran's penis is deformed, his erectile dysfunction, although significant, is not entitled to a compensable rating. The Board appreciates that the Veteran has asserted that his prostate cancer residual symptomatology warrants a rating in excess of 20 percent. The evidence of record, however, does not support this contention. The Veteran's reporting of his symptoms is credible. Layno v. Brown, 6 Vet. App. 465 (1994). That being said, there is no evidence in the record which indicates that he possesses the training or credentials to competently state the severity of his prostate cancer residuals. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). For these reasons, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for residuals of prostate cancer with erectile dysfunction during the entire appeal period, and the claim must be denied. As the preponderance of evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Legal Criteria for Service Connection Claims Service connection for VA compensation purposes will be granted for a disability resulting from disease or personal injury incurred in the line of duty or for aggravation of a preexisting injury in the active military, naval or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Alternatively, service connection may be granted on a presumptive basis for certain chronic diseases as outlined in 38 C.F.R. § 3.309(a) if they are shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Establishing that a purported injury or disease is connected to service, such that a veteran is entitled to potential benefits, requires competent and credible evidence of the following three things: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship, i.e. a nexus, between the disease or injury in service and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). With regards to a showing of chronic disease in service, it is necessary for the Veteran to demonstrate a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Where the disease identity is established, there is no requirement of evidentiary showing of continuity. However, continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995). The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C. § 1154(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Bone Disorder The Veteran asserts that his bone disorder, currently diagnosed as osteopenia of the neck of the left femur, is secondary to the treatment for his service-connected prostate cancer. Specifically, he contends that he did not develop the bone disorder until after undergoing radiation therapy to treat his prostate cancer in 2003. A review of the Veteran's service treatment records shows that the Veteran was never diagnosed with or treated for any symptoms of a bone disorder while in service. He was evaluated as having no abnormalities on his November 1965 discharge examination. As the Veteran has never contended that he incurred a bone disorder during service, and as there is no evidence in the record to suggest that this is the case, the Board finds that service connection on a direct basis pursuant to 38 C.F.R. § 3.303(a) is not warranted. Post-service, a bone density examination report prepared by I.V. Family Care Medical Group Bone Density Clinic and dated in January 2011 indicates that the Veteran was assessed as having a bone disorder; however, the testing revealed a normal bone mineral density. Thereafter, an October 2012 bone density examination at the Veteran's local VA medical center resulted in a diagnosis of osteopenia of the hip. That examination also showed no evidence of metastatic bone disease nor any evidence of a widespread osseous process. Subsequent VA and private medical records show continued treatment for osteopenia of the hip. In a September 2016 letter, a Dr. L.S., who identified as the Veteran's treating physician at his local VA medical clinic, stated that the Veteran developed osteopenia many years after receiving treatment for his prostate cancer. After noting that osteopenia is a well-established risk of cancer treatment such as radiation therapy, Dr. L.S. opined that the osteopenia was directly related to the Veteran's prostate cancer treatment. During the September 2016 hearing, the Veteran reported that he experienced chronic pain in his left hip that radiated down his left leg. He stated that the pain did not begin until after his radiation therapy to treat his prostate cancer and contended that the condition was due to that therapy and other associated treatment for his cancer. The Veteran was afforded an examination to evaluate the nature and etiology of his bone disorder in March 2017. The examiner reported the Veteran's history of an osteopenia diagnosis in 2012 following a bone density examination and his continued treatment thereafter. The examiner then opined that it was less likely than not that the osteopenia was incurred in service, on the basis of the complete lack of records showing any indication of a bone disorder in service. Furthermore, the examiner also opined that it was less likely than not that the osteopenia was permanently aggravated by the prostate cancer treatment, as the radiation to the prostate was clinically distant enough from the neck of the femur to conclude that any radiation used on the prostate would not impact the Veteran's left hip. Upon consideration of the record, the Board finds that there is insufficient evidence to warrant a grant of service connection for a bone disorder. The Board acknowledges that the Veteran has competently asserted that he did not develop left hip pain until after undergoing radiation therapy. Layno v. Brown, 6 Vet. App. 465 (1994). However, he has not shown that he has the requisite training and credentials to competently conclude that his bone disorder is attributable to service, to include as secondary to treatment for his service-connected prostate cancer. Jandreau, 491 F.3d at 1372. The Veteran's assertions must be considered in light of the medical opinions of record. Where, as here, there are conflicting medical opinions in the claims file, the Board is entitled to independently assess the opinions and make a determination as to relative weight to assign to each opinion. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). If the Board finds that a private opinion is less persuasive than an opinion offered by a VA medical examiner, it may attribute more probative weight to the VA medical examiner's opinion, so long as that determination is supported by an adequate statement of reasons or bases for doing so. D'Aires v. Peake, 22 Vet. App. 97, 107-108 (2008). On the one hand, the opinion offered by the March 2017 VA examiner is supported by a thorough evaluation of the Veteran's medical history and a discussion of the relative distant proximity of the left hip osteopenia to the prostate which underwent radiation therapy. When evaluating the probative value of a medical opinion, the Board notes that any opinion must be supported by sufficient evidence and cannot necessarily rely solely on the claim file alone. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008). A mere conclusory opinion is insufficient to allow the Board to make an informed decision as to the weight to assign to the opinion. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). The probative value of a medical opinion is also generally based on the scope of the examination or review, as well as the relative merits of the analytical findings; the probative weight of a medical opinion may be reduced if the physician fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Here, not only did the examiner rely on the available treatment records, but they also discussed how the location of the left hip osteopenia is clinically distant from the area of the Veteran's body that actually received the radiation therapy (i.e., his prostate). Accordingly, the Board affords the March 2017 VA examiner's opinion with significant probative weight. By contrast, although Dr. L.S. referred to information available in the record, they did not indicate that they reviewed the entire claims file before setting forth their opinion. Moreover, while they did refer to medical literature that supported the conclusion that the bone disorder was due to the radiation therapy, they did not relate this medical literature to the particular circumstances of the Veteran's bone disorder. In summation, while Dr. L.S.'s opinion provides a possible explanation for the development of the bone disorder after the Veteran underwent radiation therapy, the opinion does not provide any rationale for why Dr. L.S. believed that the bone disorder was attributable to the radiation therapy as opposed to any other possible explanation. Therefore, the Board finds that the opinion has little probative merit. Thus, the Board finds that the opinion offered by the March 2017 VA examiner is the most persuasive opinion of record and warrants the greatest probative weight on the issue at hand. In light of the lack of any other supporting evidence tending to show that the bone disorder was permanently aggravated by the treatment for the prostate cancer, the Board also concludes that the preponderance of the evidence weighs against the Veteran's claim of service connection for a bone disorder as secondary to the prostate cancer treatment pursuant to 38 C.F.R. § 3.310. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (holding that the Board can "weigh the absence of contemporaneous medical evidence against the lay evidence of record"). The Veteran may still be entitled to service connection if all of the evidence establishes that the bone disorder is otherwise attributable to service. 38 C.F.R. § 3.303(d). Here, however, there is no objective evidence of incurrence in service, and there is a nearly 50 years gap between discharge from service and the osteopenia diagnosis. Furthermore, the Board already discussed the Veteran's lay assertions that the bone disorder is attributable to the prostate cancer treatment and found them lacking in probative value. Thus, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran's bone disorder is otherwise attributable to service. Service connection for a bone disorder under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim of service connection for a bone disorder in total must be denied. In summary, as the preponderance of the evidence is against the Veteran's service connection claim, the benefit-of-the-doubt standard of proof does not apply, and the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). Hypertension The Veteran asserts that his currently diagnosed hypertension is secondary to the treatment for his service-connected prostate cancer. Specifically, he contends that he did not develop hypertension until after undergoing radiation therapy to treat his prostate cancer in 2003. A review of the Veteran's service treatment records does not reveal any complaints, findings, treatment, or diagnoses relating to hypertension. On the July 1963 induction examination, the Veteran's blood pressure reading was 112/68, while on the November 1965 separation examination, the blood pressure reading was 110/68. There are no further blood pressure readings available in the Veteran's service treatment records. These two readings do not qualify for a diagnosis of hypertension for VA purposes. 38 C.F.R. § 4.104, Diagnostic Code 7101. The first post-service medical record showing a diagnosis of hypertension is a private outpatient record prepared by a Dr. M.R. and dated in January 2011. Subsequent VA and private medical records show continued treatment for hypertension. Dr. L.S. in her September 2016 letter stated that the Veteran also developed hypertension "many years" after receiving treatment for his prostate cancer. After noting that hypertension is a well-established risk of cancer treatment such as radiation therapy and that some classes of chemotherapeutic agents are known to induce hypertension, Dr. L.S. opined that the hypertension was directly related to the Veteran's prostate cancer treatment. During the September 2016 hearing, the Veteran reported that he was first diagnosed with hypertension in 2005. He contended that the hypertension was due to the radiation therapy and other associated treatment for his prostate cancer. The Veteran was afforded an examination to evaluate the nature and etiology of his bone disorder in March 2017. The examiner reported the Veteran's history of diagnosis with hypertension in approximately 2012, but noted that the Veteran stated he had been placed on hypertensive medication about 10 years prior to the examination. After confirming the treatment plan and continued diagnosis of hypertension, the examiner opined that it was less likely than not that the hypertension was incurred in service, on the basis of the complete lack of records showing any indication of hypertension in service and the first diagnosis of hypertension over 45 years after discharge. Furthermore, the examiner opined that it was less likely than not that the hypertension was permanently aggravated by the prostate cancer treatment, as there was a nine year gap between the radiation therapy and the hypertension diagnosis. The examiner also noted that the Veteran had a long history of well-controlled hypertension, which did not support a determination that the hypertension was aggravated by a service-connected condition. Upon consideration of the record, the Board finds that the preponderance of the evidence is against a grant of service connection for hypertension, to include as secondary to service-connected prostate cancer residuals. To begin, the evidence does not show, and the Veteran does not assert, that he incurred hypertension while in service or within a year of his discharge. Accordingly, neither direct service connection pursuant to 38 C.F.R. § 3.303(a) nor presumptive service connection for chronic conditions that develop within one year of service under 38 C.F.R. § 3.303(b) is warranted. The Board will thus focus its analysis on whether the Veteran's hypertension was aggravated beyond its normal progression by the treatment for prostate cancer. The Board acknowledges that the Veteran has consistently maintained that his hypertension was caused by the treatment for his prostate cancer, and that he is competent to report his symptoms of hypertension and prostate cancer residuals and when those symptoms began to manifest. Layno, 6 Vet. App. at 465. However, there is no evidence in the record which indicates that the Veteran possesses the competence through training or credentials to conclude that his hypertension is attributable to or aggravated by the treatment for his prostate cancer. Jandreau, 491 F.3d at 1372. The Veteran's assertions must be considered in light of the medical opinions of record. Again, the Board is entitled to independently assess the conflicting opinions of record and make a determination as to relative weight to assign to each opinion. Madden, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The opinion offered by the March 2017 VA examiner is supported by a thorough evaluation of the Veteran's medical history and a discussion of the temporal proximity between the radiation therapy in 2003 and the diagnosis of hypertension some eight or nine years later. Furthermore, the examiner noted that the hypertension had been well under control for the five or more years that the Veteran had been receiving treatment for it, which suggested that it had not been aggravated by the prostate cancer treatment. As the March 2017 VA examiner supported their opinion with a thorough rationale that took into consideration the entire medical record, the Board accords it significant probative weight. Sklar, 5 Vet. App. at 140. By contrast, although Dr. L.S. referred to information available in the record, they did not indicate that they reviewed the entire claims file before setting forth their opinion. While Dr L.S. related hypertension to treatment, including radiation, for prostate cancer, it was also noted that hypertension was diagnosed "many years after" such treatment, and there is no indication that prostate cancer itself might have aggravated hypertension. The Board thus finds this rationale wanting and has determined that the opinion has little probative merit. Thus, the Board finds that the opinion offered by the March 2017 VA examiner is the most persuasive opinion of record and warrants the greatest probative weight on the issue at hand. In light of the lack of any other supporting evidence tending to show that hypertension was permanently aggravated by the treatment for the prostate cancer, the Board also concludes that the preponderance of the evidence weighs against the Veteran's claim of service connection for hypertension as secondary to the prostate cancer treatment pursuant to 38 C.F.R. § 3.310 The Veteran may still be entitled to service connection if all of the evidence establishes that hypertension is otherwise attributable to service. 38 C.F.R. § 3.303(d). Here, however, there is no objective evidence of incurrence in service, and there is an over 45 year gap between discharge from service and the hypertension diagnosis. Furthermore, the Board already discussed the Veteran's lay assertions that the hypertension is attributable to the prostate cancer treatment and found them lacking in probative value. Thus, the Board finds that the preponderance of the evidence weighs against a finding that the Veteran's hypertension is otherwise attributable to service. Service connection for hypertension under 38 C.F.R. § 3.303(d) is denied, and as such the Veteran's claim of service connection for hypertension in total must be denied. In summary, as the preponderance of the evidence is against the Veteran's service connection claim, the benefit-of-the-doubt standard of proof does not apply, and the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107(b). ORDER Entitlement to a disability rating in excess of 20 percent for residuals of prostate cancer with erectile dysfunction is denied. Service connection for a bone disorder is denied. Service connection for hypertension is denied. ____________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs