Citation Nr: 18145294 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 17-53 318 DATE: October 26, 2018 ORDER Entitlement to service connection for small intestine cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. Entitlement to service connection for kidney cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. Entitlement to service connection for liver cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. Entitlement to service connection for thyroid cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. FINDINGS OF FACT 1. The Veteran’s small intestine cancer is neither proximately due to nor aggravated beyond its natural progression by his service-connected prostate cancer and is not otherwise related to in-service herbicide agent exposure. 2. The Veteran’s kidney cancer is neither proximately due to nor aggravated beyond its natural progression by his service-connected prostate cancer and is not otherwise related to in-service herbicide agent exposure. 3. The Veteran’s liver cancer is neither proximately due to nor aggravated beyond its natural progression by his service-connected prostate cancer and is not otherwise related to in-service herbicide agent exposure. 4. The Veteran’s thyroid cancer is neither proximately due to nor aggravated beyond its natural progression by his service-connected prostate cancer and is not otherwise related to in-service herbicide agent exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for small intestine cancer are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a). 2. The criteria for service connection for kidney cancer are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a). 3. The criteria for service connection for liver cancer are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a). 4. The criteria for service connection for thyroid cancer are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to February 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision. In May 2015, a new Appointment of Veterans Service Organization as Claimant’s Representative (VA Form 21-22) was received at the RO appointing the representative listed on the title page above. The Board recognizes this change in representation. In December 2017, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The Board notes that the Veteran’s claims were previously before the Board in April 2018. At that time, the Board found new and material evidence had been submitted and reopened the Veteran’s claims for service connection for liver cancer and kidney cancer. Service Connection The Veteran seeks entitlement to service connection for small intestine cancer, kidney cancer, liver cancer, and thyroid cancer. Specifically, the Veteran maintains that his small intestine cancer, kidney cancer, liver cancer, and thyroid cancer were caused by in-service herbicide agent exposure or by his service-connected prostate cancer. For the following reasons, the Board finds that service connection for small intestine cancer, kidney cancer, liver cancer, and thyroid cancer is not established. Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection 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 or “medical nexus” between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303(a). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires: (1) competent evidence of current disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either: (a) caused by; or (b) aggravated by a service-connected disability. Id.; see Allen v. Brown, 7 Vet. App. 439 (1995). VA has also established a presumption of service connection for certain diseases found to be associated with herbicide exposure. See 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). Absent affirmative evidence to the contrary, such diseases will be service connected even if there is no evidence of the disease during service, provided that herbicide exposure is established. Id.; 38 C.F.R. § 3.307(d). The term “herbicide agent” means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 (the Vietnam Era). 38 C.F.R. § 3.307(a)(6). A veteran who, during active military service, served in the Republic of Vietnam during the Vietnam Era is presumed to have been exposed to such herbicide agents. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6). Because the Veteran served in the Republic of Vietnam during the Vietnam Era, as shown by his service personnel records, he is presumed to have been exposed to an herbicide agent. See 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6). At the outset, the Veteran’s small intestine cancer, kidney cancer, liver cancer, and thyroid cancer do not qualify for the presumption of service connection based on herbicide agent exposure under 38 C.F.R. § 3.309(e). Accordingly, service connection on a presumptive basis under § 3.309(e) is not established for the Veteran’s small intestine cancer, kidney cancer, liver cancer, and thyroid cancer. Although presumptive service connection based on herbicide exposure is not available for the Veteran’s claims for service connection for small intestine cancer, kidney cancer, liver cancer, and thyroid cancer, service connection may still be established with proof of direct causation. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (observing that the “availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange”); cf. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection may also be established on a secondary basis. 38 C.F.R. § 3.310(a). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to service connection for small intestine cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. The Board concludes that, while the Veteran has a current diagnosis of small intestine cancer, and evidence shows that he is presumed to have been exposed to an herbicide agent, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of small intestine cancer began during service or is otherwise related to an in-service injury, event, or disease, to include herbicide agent exposure. 38 U.S.C. §§ 1110, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). The question of whether the Veteran’s small intestine cancer is linked to his presumed herbicide agent exposure was posed to a VA examiner after the April 2018 Board remand. The June 2018 VA examiner opined that the Veteran’s small intestine cancer is not at least as likely as not related to his presumed in-service herbicide agent exposure. The examiner provided that medical literature does not support herbicide agent exposure as a cause for small intestine cancer and the risk factors for the Veteran’s specific type of small intestine cancer have not been established. In terms of medical literature, the examiner cited studies from the Institute of Medicine that found no evidence of biologic plausibility of an association between Agent Orange exposure and tumors of the colon, rectum, or small intestine, and from the American Cancer Society that provided cancers of the gastrointestinal system have been studied extensively in Veterans that served in the Republic of Vietnam and those with herbicide agent exposure and no link has been found between gastrointestinal system cancer and any such exposure. Additionally, the examiner indicated that with the exception of hereditary syndrome and possible associations with smoking, that alcohol, diabetes, and obesity, the pathogenesis are risk factors for the Veteran’s specific type of small intestine cancer, a “well-differentiated neuroendocrine tumor,” are almost entirely unknown. Well-differentiated means that cancerous cells strongly resemble the tissue of origin. The examiner’s opinion is highly probative, because it is based on an accurate medical history, includes relevant VA treatment record entries, and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The preponderance of the evidence is also against finding that the Veteran’s small intestine cancer is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected prostate cancer. 38 U.S.C. §§ 1110, Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). The June 2018 VA examiner opined that the Veteran’s small intestine cancer is instead a primary small intestine cancer and not a prostate cancer metastasis. The rationale was that the Veteran’s pathology reports, lab results, and oncology records demonstrate that the Veteran’s small intestine cancer is not linked to his service-connected prostate cancer. For example, the Veteran’s small intestine biopsy, specifically documents that Veteran’s tumor is a “well-differentiated neuroendocrine tumor.” The examiner further provided that if the Veteran’s small intestine cancer was a prostate cancer metastasis, laboratory testing should show an abnormally elevated prostate-specific antigen, however the Veteran’s prostate-specific antigen has been consistently undetectable since 2007. Lastly, the examiner provided that the Veteran’s most recent oncology visit in February 2018 showed his history of prostate cancer as adenocarcinoma of the prostate status post prostatectomy in 2002 without evidence of recurrence. The Veteran and his representative maintain that his small intestine cancer is related to his service-connected prostate cancer. See December 2017 Hearing Transcript. However, they are not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Further, there is no competent medical evidence that indicates that the Veteran’s small intestine cancer is linked to his service-connected prostate cancer. Rather, the Veteran’s VA treatment records and the June 2018 medical opinion indicate that the Veteran’s small intestine cancer is a primary cancer and not a prostate cancer metastasis. Consequently, the Board gives more probative weight to the competent medical evidence. The Veteran also stated that he has been told by his treating physician that his small intestine cancer is connected to his service-connected prostate cancer or radiation exposure. See December 2017 Hearing Transcript. While the Veteran is competent to relay what his treating physician told him, this constitutes indirect evidence concerning what the treating physician purportedly said, and is much more general in nature than the VA medical opinion detailed above. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (finding that the connection between what a physician said and the layman’s account of what he purportedly said, filtered through a layman’s sensibilities, is too attenuated and inherently unreliable to constitute medical evidence); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence”). Additionally, the Veteran stated that he was not treated medically with radiation and that he was unaware whether he was exposed to any ionizing radiation during active service during his video-conference hearing. Thus, the Veteran’s testimony is afforded less probative weight than the June 2018 VA medical opinion. In sum, the preponderance of the evidence weighs against service connection for small intestine cancer as the competent evidence of record demonstrates the Veteran’s small intestine cancer is not linked to his active service. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for small intestine cancer is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App.at 55. 2. Entitlement to service connection for kidney cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. The Board concludes that, while the Veteran has a current diagnosis of kidney cancer, and evidence shows that he is presumed to have been exposed to an herbicide agent, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of kidney cancer began during service or is otherwise related to an in-service injury, event, or disease, to include herbicide agent exposure. 38 U.S.C. §§ 1110, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). The question of whether the Veteran’s kidney cancer is linked to his presumed herbicide agent exposure was posed to a VA examiner after the April 2018 Board remand. The June 2018 VA examiner opined that the Veteran’s kidney cancer is not at least as likely as not related to his presumed in-service herbicide agent exposure. The examiner provided that medical literature does not support herbicide agent exposure as a cause for kidney cancer and that it is most likely that other risk factors caused his kidney cancer. In terms of medical literature, the examiner cited a study from the Institute of Medicine that found inadequate or insufficient evidence to determine whether there is an association between Agent Orange and kidney cancers and UpToDate, an evidence-based clinical resource, that shows kidney cancer is associated with exposure to some chemicals, but not Agent Orange. The examiner further opined that the Veteran’s kidney cancer is more likely due to other risk factors, including gender, hypertension, and obesity. The examiner cited medical literature and the Veteran’s medical history in support of the finding that his other risk factors show that his gender, and history of hypertension and obesity point to him having an increased risk for kidney cancer. The examiner’s opinion is probative, because it is based on an accurate medical history, relevant medical literature, includes relevant VA treatment record entries, and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. The preponderance of the evidence is also against finding that the Veteran’s kidney cancer is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected prostate cancer. 38 U.S.C. §§ 1110, Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). The June 2018 VA examiner opined that the Veteran’s kidney cancer is instead a primary kidney cancer and not a prostate cancer metastasis. The rationale was that the Veteran’s pathology reports, lab results, and oncology records demonstrate that the Veteran’s kidney cancer is not linked to his service-connected prostate cancer. The examiner provided that the Veteran’s kidney biopsy documents the Veteran’s tumor as renal cell carcinoma, clear cell type and that clear cell carcinomas arise from the proximal tubule of the kidney, not the prostate. The examiner again provided that the Veteran’s prostate-specific antigen has been consistently undetectable since 2007 and his most recent oncology visit in February 2018 showed his history of prostate cancer as adenocarcinoma of the prostate status post prostatectomy in 2002 without evidence of recurrence, which both support a finding that his kidney cancer is not linked to his service-connected prostate cancer. The Veteran and his representative maintain that his kidney cancer is related to his service-connected prostate cancer. See December 2017 Hearing Transcript. However, they are not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. Further, there is no competent medical evidence that indicates that the Veteran’s kidney cancer is linked to his service-connected prostate cancer. Rather, the Veteran’s VA treatment records and the June 2018 medical opinion indicate that the Veteran’s kidney cancer is a clear cell type and not related to his service-connected prostate cancer. Consequently, the Board gives more probative weight to the competent medical evidence. The Veteran also stated that he has been told by his treating physician that his kidney cancer is connected to his service-connected prostate cancer or radiation exposure. See December 2017 Hearing Transcript. Again, while the Veteran is competent to relay what his treating physician told him, this constitutes indirect evidence concerning what the treating physician purportedly said, and is much more general in nature than the VA medical opinion detailed above. See Robinette, 8 Vet. App. at 77; see also Madden, 125 F.3d at 1481. As noted above, the Veteran stated that he was not treated with radiation and that he was unaware whether he was exposed to any ionizing radiation during active service during. Thus, the Veteran’s testimony is afforded less probative weight than the June 2018 VA medical opinion. In sum, the preponderance of the evidence weighs against service connection for kidney cancer as the competent evidence of record demonstrates the Veteran’s kidney cancer is not linked to his active service. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for kidney cancer is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App.at 55. 3. Entitlement to service connection for liver cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. The Board concludes that, while the Veteran has a current diagnosis of liver cancer, and evidence shows that he is presumed to have been exposed to an herbicide agent, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of liver cancer began during service or is otherwise related to an in-service injury, event, or disease, to include herbicide agent exposure. 38 U.S.C. §§ 1110, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). The question of whether the Veteran’s liver cancer is linked to his presumed herbicide agent exposure was posed to a VA examiner after the April 2018 Board remand. The June 2018 VA examiner opined that the Veteran’s liver cancer is not at least as likely as not related to his presumed in-service herbicide agent exposure. The examiner provided that medical literature does not support herbicide agent exposure as a cause for liver cancer and that his liver cancer is almost certainly due to his history of cirrhosis. In terms of medical literature, the examiner cited studies from the Institute of Medicine that found there was inadequate or insufficient evidence to determine whether there is an association between Agent Orange and hepatobiliary cancer and the American Cancer Society found American Cancer Society that provided cancers of the gastrointestinal system have been studied extensively in Veterans that served in the Republic of Vietnam and those with herbicide agent exposure and no link has been found between gastrointestinal system cancer and any such exposure. The examiner further opined that the veteran’s liver cancer is almost certainly due to his history of cirrhosis as the Veteran was diagnosed with cirrhosis of the liver in March 2010. In support, the examiner cited medical literature that indicates that cirrhosis of any etiology is the single largest risk factor in the development of hepatocellular carcinoma and that most, but not all, people who develop liver cancer already have some evidence of cirrhosis. The examiner’s opinion is probative, because it is based on an accurate medical history, relevant medical literature, includes relevant VA treatment record entries, and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. The preponderance of the evidence is also against finding that the Veteran’s liver cancer is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected prostate cancer. 38 U.S.C. §§ 1110, Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). The June 2018 VA examiner opined that the Veteran’s liver cancer is instead a primary liver cancer and not a prostate cancer metastasis. The rationale was that the Veteran’s pathology reports, lab results, and oncology records demonstrate that the Veteran’s liver cancer is not linked to his service-connected prostate cancer. The examiner provided that the Veteran’s VA treatment record show the Veteran’s tumor is well-differentiated hepatocellular neoplasm. As noted above, well-differentiated means that cancerous cells strongly resemble the tissue of origin. The examiner again provided that the Veteran’s prostate-specific antigen has been consistently undetectable since 2007 and his most recent oncology visit in February 2018 showed his history of prostate cancer as adenocarcinoma of the prostate status post prostatectomy in 2002 without evidence of recurrence, which both support a finding that his liver cancer is not linked to his service-connected prostate cancer. The Veteran and his representative maintain that his liver cancer is related to his service-connected prostate cancer. See December 2017 Hearing Transcript. However, they are not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. Further, there is no competent medical evidence that indicates that the Veteran’s liver cancer is linked to his service-connected prostate cancer. Consequently, the Board gives more probative weight to the competent medical evidence. The Veteran also stated that he has been told by his treating physician that his liver cancer is connected to his service-connected prostate cancer or radiation exposure. See December 2017 Hearing Transcript. As noted above, while the Veteran is competent to relay what his treating physician told him, this constitutes indirect evidence concerning what the treating physician purportedly said, and is much more general in nature than the VA medical opinion detailed above. See Robinette, 8 Vet. App. at 77; see also Madden, 125 F.3d at 1481. Again, the Veteran stated that he was not treated with radiation and that he was unaware whether he was exposed to any ionizing radiation during active service during. Thus, the Veteran’s testimony is afforded less probative weight than the June 2018 VA medical opinion. In sum, the preponderance of the evidence weighs against service connection for liver cancer as the competent evidence of record demonstrates the Veteran’s liver cancer is not linked to his active service. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for liver cancer is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App.at 55. 4. Entitlement to service connection for thyroid cancer, to include as due to herbicide agent exposure or as secondary to service-connected prostate cancer is denied. The Board concludes that, while the Veteran has a current diagnosis of thyroid cancer, and evidence shows that he is presumed to have been exposed to an herbicide agent, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of thyroid cancer began during service or is otherwise related to an in-service injury, event, or disease, to include herbicide agent exposure. 38 U.S.C. §§ 1110, 5107(b); Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(a), (d). The question of whether the Veteran’s thyroid cancer is linked to his presumed herbicide agent exposure was posed to a VA examiner after the April 2018 Board remand. The June 2018 VA examiner opined that the Veteran’s thyroid cancer is not at least as likely as not related to his presumed in-service herbicide agent exposure. The examiner provided that medical literature does not support herbicide agent exposure as a cause for thyroid cancer. The examiner cited a study from the Institute of Medicine that found inadequate or insufficient evidence to determine whether there is an association between Agent Orange and thyroid or other endocrine cancers and UpToDate, an evidence-based clinical resource, that shows thyroid cancer is associated with radiation exposure, and not chemical exposure. The examiner also cited an American Cancer Society study that provided the main risk factors for thyroid cancer are genetic syndrome, a diet low in iodine, and radiation exposure. The examiner’s opinion is probative, because it is based on an accurate medical history, relevant medical literature, includes relevant VA treatment record entries, and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304. The preponderance of the evidence is also against finding that the Veteran’s thyroid cancer is proximately due to or the result of, or aggravated beyond its natural progression by his service-connected prostate cancer. 38 U.S.C. §§ 1110, Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). The June 2018 VA examiner opined that the Veteran’s thyroid cancer is a primary thyroid cancer and not a prostate cancer metastasis. The examiner noted that the Veteran’s VA treatment records note that the Veteran’s thyroid cancer was noted as classic, usual, conventional papillary carcinoma, which means the tissue of origin was the thyroid. The examiner again provided that the Veteran’s prostate-specific antigen has been consistently undetectable since 2007 and his most recent oncology visit in February 2018 showed his history of prostate cancer as adenocarcinoma of the prostate status post prostatectomy in 2002 without evidence of recurrence, which both support a finding that his thyroid cancer is not linked to his service-connected prostate cancer. The examiner also opined that the Veteran’s thyroid cancer is not related to radiation exposure as a result of treatment for service-connected prostate cancer. First, the examiner explained that while radiation is a known risk factor for thyroid cancer, the Veteran’s VA treatment records and his statements during the December 2017 video-conference hearing indicate that he has not been treated medically with radiation. The Veteran also advised that he was unaware whether he was exposed to any ionizing radiation during active service during the video-conference hearing. The Veteran and his representative maintain that his thyroid cancer is related to his service-connected prostate cancer. See December 2017 Hearing Transcript. However, they are not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. Further, there is no competent medical evidence that indicates that the Veteran’s thyroid cancer is linked to his service-connected prostate cancer. Consequently, the Board gives more probative weight to the competent medical evidence. The Veteran also stated that he has been told by his treating physician that his thyroid cancer is connected to his service-connected prostate cancer or radiation exposure. See December 2017 Hearing Transcript. While the Veteran is competent to relay what his treating physician told him, this constitutes indirect evidence concerning what the treating physician purportedly said, and is much more general in nature than the VA medical opinion detailed above. See Robinette, 8 Vet. App. at 77; see also Madden, 125 F.3d at 1481. Thus, the Veteran’s testimony is afforded less probative weight than the June 2018 VA medical opinion. In sum, the preponderance of the evidence weighs against service connection for thyroid cancer as the competent evidence of record demonstrates the Veteran’s thyroid cancer is not linked to his active service. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for thyroid cancer is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App.at 55. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel