Citation Nr: 1804753 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 13-10 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for multiple myeloma. REPRESENTATION Veteran represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD Dominic Jones, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1974 to November 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Although the Veteran did not request a Board hearing on his April 2013 substantive appeal, he was scheduled for one to take place in December 2013. In any case, in November 2013, the Veteran canceled the hearing. To the extent additional evidence has been received since the February 2013 statement of the case, waiver of RO consideration of the additional evidence is presumed given the date of the Veteran's substantive appeal. See 38 U.S.C.A. § 7105(e). FINDING OF FACT The Veteran's multiple myeloma is not attributable to his active service. CONCLUSION OF LAW The criteria for service connection for multiple myeloma have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet.App. 545, 552 (2008). I. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(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"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). II. Analysis The Veteran contends that his multiple myeloma is the result of his repeated heavy exposure to petroleum products, solvents and pesticides he utilized during his period of service. As a threshold matter, the Veteran has a present diagnosis of multiple myeloma that was diagnosed in 2008. See December 2010 VA examination report. Thus, the current disability element of the claim is met. Furthermore, for a portion of his service, the Veteran's duties were as a petroleum and lubricant specialist. See April 1977 service letter. Thus, the Board finds that the evidence establishes his repeated exposure to petroleum products. Therefore, the sole question is whether there is a causal relationship between his multiple myeloma and his exposure to petroleum products, which is the nexus element of the claim. The Veteran received a VA examination for his claim in December 2010. The examiner (a VA physician) acknowledged that the Veteran was "heavily exposed to petroleum products and fuels" as he refueled vehicles for a year. Nonetheless, the examiner opined that a review of the best scientific data did not make it likely that the Veteran's exposure to the fuels was the cause of his multiple myeloma. The examiner went on to state that there was less than a 50 percent chance that the Veteran's exposure was the cause of the multiple myeloma as suggested by large studies done over many years. In a June 2010 statement, the Veteran related that as described by the Mayo Clinic the "main risk factors" for multiple myeloma high levels of radiation, pesticides, and petroleum products. He then emphasized that his service duties included working in the motor pool and that he breathed highly concentrated fumes of petroleum products. He related that he was told by his oncologists and other healthcare professionals that there was a "high probability" that the onset of his cancer was caused by his exposure to these petroleum products. The Veteran also submitted online medical literature from the Mayo Clinic discussing multiple myeloma. He further submitted online medical literature from the Merck Manuals on the condition. He submitted still more medical literature highlighting that multiple myeloma has been seen more commonly than expected among farmers, wood workers, leather workers, and those exposed to petroleum products. The record also contains a June 2010 statement from a hematology and oncology VA physician that the Veteran had multiple myeloma and that "[i]t is possible for multiple myeloma to develop after exposure to petroleum products and pesticides" and that the Veteran had prolonged exposure to petroleum products during service. In March 2017, the Board obtained an additional expert medical opinion from the Veterans Health Administration (VHA). The request related that Veteran's contentions and his descriptions of his exposures to petroleum products, fumes, solvents, and pesticides. It also highlighted the medical literature the Veteran submitted. The opinion was received in May 2017 by an attending physician at a VA Medical Center who has expertise in oncology. The physician reviewed the Veteran's medical records and acknowledged the Veteran's daily exposure to petroleum products. This physician opined that it was not more likely than not that the Veteran's development of multiple myeloma was related to service. In the rationale, the physician acknowledged that some reports have suggested that the oral exposure of volatile organic compounds may increase the risk of blood cancers including myeloma. However, the physician stated there was no study that demonstrated an increased risk in servicemen or civilians exposed to other types of petroleum products. While noting that age 52-the age at which the Veteran was diagnosed with multiple myeloma-was a "relatively early age of onset," the physician nonetheless further stated that myeloma can present at a young age. Continuing, it was stated that myeloma likely arises as a result of accumulating mutations in blood stem cells and occurs in many individuals who have not served in the military or been exposed to petroleum products. Thus, it was opined, overall it was more likely than not that the Veteran's myeloma "arose spontaneously and not as a result of petroleum product exposures in the service." The Veteran's representative submitted a brief in January 2018 that advanced several arguments. First, the representative contended that the May 2017 physician did not consider and address in writing the positive medical opinions of record that found the Veteran's exposure to petroleum products at least as likely as not caused his multiple myeloma. Second, the representative argued that the May 2017 opinion did not consider and discuss the medical literature indicating that such exposure can cause the Veteran's disease. Finally, it was argued that the physician erroneously denied any such medical literature existed. These arguments were emphasized with citation to Barr v. Nicholson, 21 Vet. App. 303 (2007) and Nieves-Rodriguez v. Peak, 22 Vet. App. 295 (2008) noting that in order for a medical opinion to be probative, the examiner must be qualified to provide the opinion and that what was most important about a medical opinion was the physician's articulated, reasoned analysis based on the relevant facts. To the first argument, the Board notes that the positive medical opinions of record take the form of the Veteran's report of what medical professionals told him, and the June 2010 statement from the oncology and hematology fellow. As to the Veteran's reports, he is certainly competent to report what a physician told him about the etiology of his multiple myeloma. The Board highlights that the June 2010 statement was that "it was possible" for multiple myeloma to develop after exposure to petroleum products and pesticides and acknowledged that the Veteran had some exposure to petroleum products. Namely, that opinion recognized the possibility of some link between exposure to petroleum products and the development of multiple myeloma, and acknowledged the Veteran's exposure to petroleum products. While the May 2017 physician did not specifically reference the Veteran's reports, the physician did credit and acknowledge a link between exposure to volatile organic compounds and multiple myeloma. Thus, the same link noted in the June 2010 statement was noted by the May 2017 physician. Nonetheless, the physician then assessed, using scientific principles and reference to scientific literature that the Veteran's multiple myeloma more likely arose spontaneously. Furthermore, medical examiners are not required to discuss every favorable piece of evidence or provide reasons and bases for each decision. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). With regard to the second argument, while the May 2017 physician did not specifically reference the medical literature submitted by the Veteran, there is no requirement that the physician need specifically do so. See id. The representative in its brief highlights that what is most important is an articulated and reasoned analysis based upon the relevant facts. The May 2017 medical opinion acknowledged the relevant facts that included the Veteran's frequent exposure refueling vehicles and some scientific link between exposure to petroleum products and myeloma. The May 2017 physician than provided a reasoned analysis based on these relevant facts. This reasoned analysis was made with reference to scientific literature. Indeed, the physician highlighted that oral exposure might increase the risk of blood cancers, but dismissed the notion that there were any studies that demonstrated an increased risk in servicemen exposed to other types of petroleum products. Furthermore, the May 2017 opinion articulated that multiple myeloma likely arises as a result of mutations in blood stems cells and occurs in many who have not been exposed to petroleum products. Thus, the physician used the relevant facts and medical principles with reference to scientific literature to opine that the Veteran's myeloma was less likely than not incurred in service. Finally, to the contention that the May 2017 physician denied that medical literature existed indicating exposure to petroleum products can cause multiple myeloma, this is simply not the case. The May 2017 physician made reference to volatile organic compounds and stated that drinking such compounds had been suggested in scientific studies as increasing a risk for blood cancers including myeloma. That is the physician specifically acknowledged a link and explained that such a link was found in oral exposure-in drinking. What the physician went on to say was that there was no study to demonstrate increased risk of blood cancers in individuals exposed to other types of petroleum products, i.e., products other than the volatile organic compounds referenced earlier. This physician also highlighted that there was no documentation of precisely what petrochemicals the Veteran was exposed to. Thus, the physician did not deny the existence of any medical literature whatsoever suggesting a link between petroleum exposure and the development of multiple myeloma, just literature suggesting a link between multiple myeloma and petroleum products other than those that contained the aforementioned volatile organic compounds. Overall, the Board finds the May 2017 medical opinion adequate in this case. The physician reviewed the claims file and the Veteran's specific history of exposure to petroleum products. Using reference to medical reports and appropriate medical reasoning, the physician opined that the Veteran's multiple myeloma more likely arose spontaneously rather than as a result of his exposure to petroleum products during service. In weighing the evidence of record, the Board finds the preponderance of the evidence weighs against service connection in this case. On the one hand, the Veteran reported that doctors told him his myeloma was caused by his exposure to petroleum products during service. However, no rationale was provided through the Veteran's direct accounts supporting that link. And while the Board affords the Veteran's report some probative value, the lack of the underlying rationale behind the opinion limits such value to some extent. Next, the written opinion from June 2010 merely stating a possibility of the development of myeloma after exposure to petroleum products and acknowledging the Veteran's exposure to these products similarly has limited probative value for the same reasons. That opinion also lacks a robust articulation of the medical principles undergirding the opinion and the use of "possibility" suggests speculation, which cannot form the basis for service connection. Therefore again, the probative value of the opinion is diminished somewhat. However, the Board finds those opinions outweighed by the December 2010 VA examination and the May 2017 medical opinion. The December 2010 opinion was made after a review of the claims file and the Veteran's descriptions of his heavy exposure to petroleum products. This examiner then goes on to indicate a review of the best scientific data still did not make it likely that the Veteran's exposure to fuels was the cause of the multiple myeloma. The examiner then again referenced "large studies done over many years" that made the chance that the Veteran's exposure to petroleum products lead to his myeloma less than 50 percent. Likewise with the May 2017 opinion, unlike the Veteran's direct reports and the June 2010 opinion, the May 2017 opinion was made after a review of the claims file and articulates the basis for the opinion. The Board affords more probative value to this opinion. The Board finds the probative value of the December 2010 and May 2017 opinion together to outweigh the probative value of the Veteran's direct reports from physicians, the June 2010 opinion, and the medical literature submitted by the Veteran. Since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable and therefore service connection for multiple myeloma is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for multiple myeloma is denied. ____________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs