Citation Nr: 18150309 Decision Date: 11/15/18 Archive Date: 11/14/18 DOCKET NO. 09-32 363 DATE: November 15, 2018 REMANDED Entitlement to service connection for cause of death is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from June 1954 to March 1973, a part of which service was in the Republic of South Vietnam. The Veteran died in August 2008. The Appellant is his surviving spouse. In March 2016, the Appellant testified before the undersigned Veterans Law Judge at a videoconference hearing. An earlier Board hearing was held before a Veterans Law Judge who is no longer at the Board. Transcripts of both hearings have been associated with the claims file. Entitlement to service connection for cause of death. In opining negatively in response to the question of whether the cause of the Veteran’s death could be related to cobalt radiation the Veteran received in service to treat his cancer, the January 2013 VA examiner, based on an excerpt from a Duke University article, which she set forth, explained that “there is no evidence to support secondary service connection…. Cobalt exposure may be linked to ‘secondary polycythemia’ but NOT polycythemia vera, which is a distinct entity.” From this then, the Board understands the January 2013 VA examiner to be stating the Veteran did not have secondary polycythemia, secondary polycythemia is a diagnosis separate and apart from polycythemia vera and is therefore a diagnosis which the Veteran never received. She rendered a negative opinion as to polycythemia vera based, it appears, on the laboratory results in service showing no elevations of red blood cells, concluding the Veteran did not in fact have polycythemia vera in service and it developed much later. However, the September 2018 VA examiner, in explaining his negative opinion in regard to causation relating to exposure to Agent Orange, quotes the Cleveland Clinic: “Doctors classify [polycythemia vera] into 2 types. The cause of the condition determines each type.” The Cleveland Clinic then refers to “primary polycythemia vera” and “secondary polycythemia vera” as having separate causes, but no further distinction is discussed. It appears then that the September 2018 VA examiner, as well as the Cleveland Clinic, conceives of this disorder as one and only one diagnosis, under which there can be different causes of the disease. Additionally, the Appellant submitted “new evidence” on polycythemia vera in her May 2013 correspondence, which contains an excerpt from an article by Hoffman, Xu, Finazzi, and Barbui, entitled, “The Polycythemias,” appearing in Hoffman, Hematology: Basic Principles and Practices (5th ed. 2008), which states in part: “Because it is not regulated at the point of absorption, cobalt can be toxic to humans when consumed in excessive quantities. Excesses can cause polycythemia (increased red blood cells).…” From the foregoing, the Board is left to infer either that, although receiving cobalt radiation therapy over an extended period, the Veteran nonetheless cannot have had polycythemia vera, as that particular diagnosis cannot be caused by such exposure, or, when the disease is no longer spoken of in terms of separate diagnoses, but only in terms of different causes, it can indeed be caused by the diminished oxygen levels in the blood which do in fact result from exposure to cobalt radiation. The Board is neither prepared with knowledge and training to draw such conclusions from these opposing inferences. The question as to whether cobalt radiation therapy caused the Veteran’s polycythemia vera is in itself a straightforward one and must be answered by an appropriate medical expert. The matter is REMANDED for the following action: 1. Arrange for a review of the Veteran’s claims file conducted by an examiner with an appropriate specialty for producing findings for polycythemia vera, to include any variation of that name when characterized as “primary” and “secondary.” The complete electronic claims file must be made available to the examiner in conjunction with the examination. The examiner should detail all findings. 2. The examiner is requested to note from the claims file that, in her opinion, the January 2013 VA examiner states, based on the Duke University article she cites, “Cobalt exposure may be linked to ‘secondary polycythemia’ but NOT polycythemia vera, which is a distinct entity.” The examiner is also requested to note from the claims file that, in his opinion, the September 2018 VA examiner quotes information provided by the Cleveland Clinic, either in print or perhaps on a web page, stating: “What causes polycythemia vera? Doctors classify [polycythemia vera] into 2 types. The cause of the condition determines each type.” The excerpt than proceeds to discuss the types, which it refers to as “primary polycythemia vera” and “secondary polycythemia vera.” Other than separate causes, no further distinction is discussed. The examiner is further requested to review the Appellant’s May 17, 2013 correspondence, containing an excerpt from the article, “The Polycythemias,” by Hoffman, Xu, Finazzi, and Barbui. The examiner is requested to render opinions, addressing the following: (a) Whether it is more likely than not (more than a 50 percent probability) or less likely than not (less than a 50 percent probability) that the Veteran’s type of polycythemia vera is either primary or secondary. (b) Whether it is more likely than not (more than a 50 percent probability) or less likely than not (less than a 50 percent probability) that the Veteran’s type of polycythemia vera is caused by or etiologically related to the Veteran’s in-service cobalt radiation therapy, employed in relation to the manifestation of a cancerous tumor on his right testis and subsequent orchiectomy and removal of a mass from the retroperitoneal space in March 1967. The opinions must be explained by an adequate rationale, by which the examiner’s conclusions are supported by direct references to clinical findings made on examination, to the Veteran’s treatment records and/or to medical literature. The examiner should comment on the findings and opinions of other examiners, which appear in the record, as well as the excerpt of the article, “The Polycythemias,” by Hoffman, Xu, Finazzi, and Barbui, submitted to the claims file in the Appellant’s May 17, 2013 correspondence. Findings should be reconciled with other records on file to the extent possible. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Franke, Associate Counsel