Citation Nr: 18143198 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-32 353 DATE: October 18, 2018 ORDER Entitlement to service connection for polycythemia vera is denied. FINDING OF FACT The Veteran’s polycythemia vera is not etiologically related to active service, to include as due to exposure to toxic chemicals therein. Further, the evidence of record fails to show that the condition was manifested to a compensable degree within one year of separation. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for polycythemia vera have not been met. 38 U.S.C. §§ 1110; 1155, 5107 (West 2012); 38 C.F.R. § 3.303 (d); 3.309 (2018) REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Coast Guard from November 1968 to October 1969, April 1970 to October 1971, November 1971 to November 1972, December 1972 to March 1980, April 1980 to December 1982, from November 15, 1985 to December 31, 1988. In an informal hearing conference, dated July 2016, the Veteran acknowledged that a nexus opinion linking his polycythemia vera to chemical exposure in service had not been associated with the claims file. He stated that the required opinion would be obtained from his treating physician. To date, none has been associated with the claims file. Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131; 38 C.F.R. §§ 3.303 (a), 3.304. Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical ‘nexus’ requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a). For certain chronic diseases, including leukemia or a malignant tumor, service connection can be presumed without showing evidence of such disease having been incurred during a period of service, if the disease has manifested to a degree of ten percent or more within one year from the date of separation. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). If there is no manifestation within one year of service, service connection for a recognized chronic disease can still be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. Continuity of symptomatology requires that the chronic disease have manifested in service. 38 C.F.R. § 3.303 (b). In service manifestation means 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. In this case, the Veteran does not assert nor does the evidence reveal that his polycythemia vera was incurred in service or had its onset within one year of separation. Therefore, service connection on a presumptive basis is not warranted. Accordingly, the Board will restrict its focus to consideration the evidence for purposes of establishing service connection on a direct basis. In determining whether service connection is warranted for a disorder, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for polycythemia vera The Veteran asserts that his current diagnosis of polycythemia vera was caused by exposure to toxic chemicals during active service, to include trichloroethylene (TCE), tetrachloroethylene (PCE), and benzene. Specifically, he contends that toxic solvents were used to clean electric equipment and he was routinely exposed to fumes from their use in areas with minimal ventilation. He denied use of a breathing apparatus. On review of the record, the Board finds that the preponderance of the evidence is against the claim. Service treatment records are silent for symptoms, treatment, or a diagnosis of a blood disorder. At enlistment in October 1968, a normal physical evaluation was indicated. No complaints of a blood disorder were referenced in the report of medical history baring the same date. In March 1970, a report of medical examination indicated that the Veteran was qualified for overseas service. A physical examination in December 1977 noted high bloods levels. Additional examinations in March 1980, May 1980, September 1985, and July 1988 specifically referenced blood level findings. For men, higher than normal hemoglobin levels are generally defined as more than 17.5 grams (g) of hemoglobin (Hgb or Hb) per deciliter (dL) of blood. In service, the Veteran’s hemoglobin levels ranged from 15.0-16.6. No mention of a blood disorder was indicated on his separation examination in 1988. Military personnel records show that the Veteran served aboard the USS Ironwood from April 1970 to October 1971. His military occupational specialty was listed as general electric LM100 gas turbine operation and maintenance. No reference to use or exposure to toxic chemicals or contaminates were noted the Veteran’s service treatment or military personnel records. Post-service treatment records show a current diagnosis of polycythemia vera. In a September 1999, the Veteran was evaluated for an elevated white blood count. Laboratory results showed a hemoglobin level of 17.7. In January 2000, an oncology note referenced a suspicion of polycythemia vera. The examination report noted that a routine physical examination the previous summer revealed abnormal blood counts. During active, the Veteran reported numerous instances of abnormal blood counts however, no specific findings were indicated. The January 2000 examination report suggested his history of excessive smoking was the possible cause of the Veteran’s elevated blood counts. A myeloproliferative disorder was also suggested. An outpatient clinic record, dated December 2003, indicated that a diagnosis of polycythemia vera was warranted based upon recent laboratory findings. The diagnostic results show a hemoglobin of 18.0. In April 2013, a Disability Benefits Questionnaire was prepared by the Veteran’s private physician. The report listed a date of diagnosis as 1998. Diagnostic findings included a hemoglobin level of 11.9 and a positive finding for a JAK-2 mutation. In July 2015, a radiation oncology evaluation confirmed the Veteran’s diagnosis of polycythemia vera. The original date of diagnosis was listed as March 2013. An additional diagnosis of macrocytosis was rendered and the condition was deemed causally related to prescribed medication, Hydrea. The Veteran denied any adverse effects with use of prescribed dosage. In April 2016, the Veteran underwent a VA examination. Current diagnoses included polycythemia vera and macrocytosis. The Veteran’s blood counts were described as well controlled on Hydrea. Antineoplastic chemotherapy was listed as an additional treatment. Current symptoms included decreased stamina, reduced strength, and easy fatigability. Following the clinical evaluation, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran’s polycythemia vera was incurred in or caused by the active service, to include exposure to toxic chemicals therein. In support of the stated conclusion, the examiner noted that the Department of Health and Human Services (DHHS) determined that tetrachloroethylene may reasonably be anticipated to be a carcinogen. Tetrachloroethylene has been shown to cause liver tumors in mice and kidney tumors in male rats. Long-term exposure to high-levels of benzene in the air has been linked to leukemia, particularly acute myelogenous leukemia (AML). AML is a cancer of the blood-forming organs. Exposure to ionizing radiation and toxins (e.g. benzene) has been suggested as a risk factor, although the majority of patients presenting with polycythemia vera have no evidence of risk exposure. The examiner also noted that the mutation that causes polycythemia vera is thought to affect a protein switch that tells the cells to grow. Specifically, it is a mutation in the protein JAK-2. Although the cause of the mutations seen in polycythemia vera is unclear, researchers believe it is acquired, rather than inherited from a parent. The risk of polycythemia vera increases with age and is more common in adults older than 60, though the disease can occur at any age. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of current symptoms, their impact on daily living and employment, and such reporting is deemed credible. Review of the record includes multiple lay statements, to include in his July 2018 Appellate Brief, indicating that the Veteran was exposed to toxic chemicals and solvents in service. Specifically, the Veteran reported working as an electrician in the Coast Guard where he was frequently exposed to chemicals, cleaning solvents, and diesel fuel especially during work in the engine room. Exposure to toxic fumes from use of cleaning solvents in confined spaces with poor ventilation was also reported. The Veteran referenced elevated blood count levels in service, however, he contends that their origin was never investigated. While the Board recognizes the Veteran’s lay assertions, an etiological opinion as to causation is a medical determination which is typically outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Further, there is no evidence that Veteran possesses the required training to diagnose polycythemia vera or opine as to its etiology. To the extent his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. On review of the record, the Board finds that service connection is not warranted. Review of service treatment records show a single reference to elevated blood levels however; there is no evidence that a formal diagnosis was ever rendered. In fact, multiple reports of medical examination show hemoglobin levels within normal ranges. Post-service treatment records indicate elevated hemoglobin levels and a diagnosis of polycythemia vera was rendered on or about 1998. A private treatment record, dated January 2000, suggested that the Veteran’s elevated hemoglobin levels were causally related to his history excessive smoking. At no time has a nexus been established between the Veteran’s diagnosis of polycythemia vera and his alleged exposure toxic chemicals during active service. On VA examination in April 2016, the VA examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran’s polycythemia vera was incurred in or caused by active service, to include exposure to toxic chemicals therein. In support of the state conclusion, it was noted that the mutation believed to cause polycythemia vera is likely acquired, rather than inherited from a parent. In light of the forgoing, the Board finds that the medical evidence fails to show a causal linkage between the Veteran’s diagnosis of polycythemia vera and active service. Further, even if the Board were to concede exposure to toxic chemicals and solvents during active duty, the medical evidence does not suggest a nexus between that exposure and the development of polycythemia vera years later. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for polycythemia vera must be denied. K. A. KENNERLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel