Citation Nr: 18140074 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 14-41 973 DATE: October 2, 2018 ORDER Service connection for squamous cell carcinoma of the vocal cords is granted. Service connection for gastroesophageal reflux disease (GERD) is granted. VETERAN’S CONTENTIONS Regarding his squamous cell carcinoma, the Veteran contends that it was caused by exposure to environmental hazards during his service in Southwest Asia. Comparatively, regarding GERD, the Veteran contends that he first experienced symptoms of the condition in service which continued after discharge to the present. FINDINGS OF FACT 1. The current medical evidence of record documents diagnoses of squamous cell carcinoma as well as GERD. Specifically, in November 2009, the Veteran complained to Dr. Molina of South Florida ENT Associates that he experienced episodes of moderate hoarseness. Dr. Molina noted a family history of GERD and provided a diagnosis of laryngopharyngeal reflux. A later June 2012 VA treatment record included a diagnosis of GERD. Regarding his carcinoma, a biopsy performed in January 2010 at Baptist Health’s South Miami Hospital provided a final diagnosis of infiltrating moderately differentiated keratinizing squamous cell carcinoma. Following sessions of chemotherapy and radiation therapy, in November 2010, Dr. Arnold from University of Miami Health performed a total laryngectomy upon the Veteran. 2. A review of the Veteran’s service personnel records (SPRs) indicate that the Veteran served in Iraq in support of Operation Iraqi Freedom from January 2005 to November 2005. His Department of Defense Form 214 (DD 214) indicates that his primary specialty in service was health services administration. 3. Although the Veteran was not diagnosed with carcinoma or GERD in service, an October 2005 health assessment documented that the Veteran reported experiencing symptoms of chronic cough, chest pain or pressure, frequent indigestion, and vomiting during his deployment in Southwest Asia. 4. In May 2011, Dr. Nayak—at that time a VA physician—noted the Veteran’s diagnosis of squamous cell carcinoma and prior complaints of hoarseness. The Veteran asked Dr. Nayak about the cause of his cancer and Dr. Nayak replied that the Veteran’s type of cancer was usually caused by smoking. The Veteran self-reported a limited history of smoking and stated that he was exposed to a burning area in service which had known carcinogens. The Veteran stated that he had throat symptoms closely after discharge but did not seek medical attention because he was a young man at that time. Dr. Nayak commented that while he could not determine the cause of the cancer, he agreed with the Veteran that it was unusual for a person of the Veteran’s age to develop this type of cancer. Dr. Nayak concluded that while it was “extremely difficult” to determine the cause of the Veteran’s condition, the Veteran’s in-service exposure to carcinogens was “definitely a possibility.” 5. In August 2011, the Veteran was provided a VA Gulf War examination wherein the examiner acknowledged diagnoses of GERD and squamous cell carcinoma of the left vocal cord with subglottic extension. Regarding the Veteran’s GERD, the examiner provided an onset date of 2004 and noted that the Veteran reported recurrent epigastric heartburn and regurgitation with medications provided since active duty service. The examiner stated GERD was a condition with a specific etiology and was less likely as not either part of a disability pattern or a diagnosis related to exposure in Southwest Asia. In regard to the Veteran’s carcinoma, the examiner provided an onset date of 2010 and opined that it was less likely than not indicative of either an undiagnosed illness or a diagnosable but medically unexplained chronic multi-symptom illness. The examiner then cited an article from the Mayo Clinic which stated that it is unclear what causes the mutation that leads to the development of the Veteran’s cancer. 6. In December 2011, a physician from the Miami VA Post-Deployment clinic reviewed the Veteran’s STRs and opined that the Veteran’s GERD and carcinoma were caused by his service in Southwest Asia. In support of this conclusion, the clinician stated that GERD can cause the erosion of the esophagus. However, the clinician did not explain how the carcinoma resulted from the Veteran’s Southwest Asia service or how the Veteran’s GERD was incurred in or caused by service. 7. In June 2012, the Veteran was afforded a VA respiratory conditions examination, wherein the examiner acknowledged the Veteran’s diagnosis of squamous cell carcinoma of the larynx. The examiner noted that the Veteran was stationed in Balad-Anaconda, serving as an executive officer of a medical unit, and was exposed to many burn pits. The examiner recorded that the Veteran had sore throats and breathing problems in service. Thereafter, the examiner opined that it was at least as likely as not that the Veteran’s condition was incurred in or caused by service. In support of this determination, the examiner first noted the Veteran’s complaints in post-deployment health assessments as well as a 2005 pulmonary function test (PFT) which revealed severely restricted lung volumes and a lung age equivalent of a 60-year-old man. The examiner commented that this PFT result was “wildly abnormal” and that laryngeal disorders are well known to cause restricted lung volumes. The examiner acknowledged the Veteran’s burn pit exposure in Iraq and stated that there is some suggestion in medical literature that exposure to carcinogens in burn pits could play a causal role in respiratory, head, and neck cancers. However, the examiner stated that this link has not yet been corroborated. The examiner concluded that, regardless of a link to burn pits in Iraq, the Veteran’s decreased lung volumes in PFT testing, shortness of breath, chronic cough, indigestion, chest pain, and hoarseness of voice were likely early signs of squamous cell carcinoma of the larynx. 8. Thereafter, in September 2012, another VA medical opinion was provided regarding the etiology of the Veteran’s squamous cell carcinoma. After reviewing the Veteran’s claims file, the clinician opined that it was less likely than not that the Veteran’s condition was related to service. In support of this conclusion, the clinician first stated that the Veteran had a 4-cigarette smoking history for 15 years and that he was exposed to burn pits in Southwest Asia in 2004 through 2005. The clinician then stated that smoking is a known risk factor for laryngeal cancer. The clinician concluded that while burn pit fires may be a risk factor for the development of the Veteran’s type of cancer, a linkage had not yet been had not yet been proven. Lastly, the clinician commented the Veteran’s cancer was diagnosed in 2009 and there was no record of symptoms prior to 2009. 9. In June 2018, Dr. Nayak issued another opinion regarding the etiology of the Veteran’s cancer. Dr. Nayak stated that he treated the Veteran between the years 2009 and 2016. Dr. Nayak noted that the Veteran presented with hoarseness and a vocal cord lesion at a young age and that this lesion proved to be squamous cell carcinoma. Dr. Nayak commented that the Veteran’s cancer was aggressive and had progressed from an early stage to a more advanced stage in a very short period of time. Dr. Nayak then stated that he found it extremely unusual that a patient of the Veteran’s age had this form of cancer and that he had yet to meet another patient with laryngeal cancer at the Veteran’s age. The Veteran had reported smoking for less than 10 years at the time of diagnosis and Dr. Nayak commented that other smokers with this form of cancer typically had 30 to 50 pack-year histories and became patients later in life. Dr. Nayak then discussed the 2-hit theory of cancer wherein a patient has a genetic predisposition to develop cancer which is then triggered by exposure to carcinogens. Dr. Nayak concluded that, while it was difficult to determine the etiology of the Veteran’s condition, it was “completely conceivable” that the Veteran had a genetic predisposition which was triggered by exposure to carcinogens and the burn pit environment in Southwest Asia. 10. Separate from Dr. Nayak’s opinion, in June 2018, the Veteran testified at a Board hearing that he started having heartburn, fits of coughing, and occasional vomiting in service. The Veteran stated that his symptoms were not regularly documented because he worked in a medical company and would simply ask a pharmacist in the company for something to treat his symptoms. The Veteran explained that, while in Iraq, he was stationed at Logical Support Area (LSA) Anaconda and there was a large burn pit area stationed directly across from the medical clinic where he worked. The Veteran testified that he was exposed to the fumes from the burn pits every day while he was deployed. The Veteran then stated that he had continuously experienced symptoms of heartburn and hoarseness since service, but did not seek medical attention until 2009 when his symptoms had gotten worse. Regarding his smoking history, the Veteran stated that while he did smoke in service, he was never a heavy smoker and never even smoked a pack a week. Additionally, the Veteran reported that he currently was a non-smoker and had not smoked in more than 10 to 12 years. CONCLUSIONS OF LAW 1. The criteria for service connection for squamous cell carcinoma of the vocal cords are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for service connection for GERD are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 2004 to May 2004 and from November 2004 to November 2005. These matters come before the Board of Veterans’ Appeals (Board) on appeal from March and October 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In June 2018, the Veteran and R.J. testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §1110; 38 C.F.R. § 3.303. Regulations also provide that service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). As indicated above, after reviewing the evidence of record, the Board finds that the Veteran is entitled to service connection for squamous cell carcinoma and GERD. Accordingly, the Board grants the Veteran’s appeal. (Continued on the next page)   Regarding the Veteran’s squamous cell carcinoma, the Board relies primarily upon the June 2012 VA examiner’s opinion as well as Dr. Nayak’s June 2018 opinion. The Board finds these opinions to be adequate for adjudicative purposes and supportive of a conclusion that the Veteran’s cancer first arose in service or is otherwise related to service. Although the September 2012 VA clinician opined that smoking was the cause of the Veteran’s cancer, the Board finds the Veteran’s June 2018 hearing testimony to be credible that he was not a heavy smoker. Further, the Board finds the September 2012 VA clinician’s opinion to be in conflict with Dr. Nayak’s June 2018 opinion as Dr. Nayak stated it was very unusual for a light smoker of the Veteran’s age to develop squamous cell carcinoma of the vocal cord. Turning to the issue of service connection for GERD, the Board finds credible the Veteran’s testimony that he experienced recurring heartburn in service while in Southwest Asia which then continued post-discharge. As the Veteran later received a diagnosis of GERD based upon complaints of similar symptoms, the Board finds that the Veteran’s GERD arose in service and continued to the present. Based upon these findings, service connection for GERD must be granted. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N.S. Pettine, Associate Counsel