Citation Nr: 18151263 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 17-39 364 DATE: November 16, 2018 REMANDED Entitlement to service connection for squamous cell carcinoma of the anal canal, to include as secondary to military sexual trauma is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to March 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2016 rating decision. 1. Entitlement to service connection for squamous cell carcinoma of the anal canal, to include as secondary to military sexual trauma is remanded. The Board finds that the March 2016 VA medical opinion is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate); D’Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination must be based on consideration of the claimant’s medical history and must describe the disability in sufficient detail so that the Board’s evaluation of the disability will be a fully informed one). The VA medical opinion points out that there is evidence of treatment for anal warts during his active service, the specifics of that treatment, and his related post-service medical treatment. The examiner concludes that she is unable to provide a medical opinion concerning the Veteran’s anal cancer being caused by his reported military sexual trauma without resorting to mere speculation. The medical opinion states that the fact that the Veteran experienced sexual abuse prior to his active service, a determination as to when he contracted the human papillomavirus could not be made. The examiner provides that there is a plausible relationship between human papillomavirus and the Veteran’s diagnosed positive human papillomavirus anal tumor. However, because there is no objective way to determine when the Veteran contracted the virus as sexual abuse occurred prior to his active service, any conclusion would be based on mere speculation. The March 2016 VA medical opinion failed to discuss the Veteran’s January 2012 Initial Posttraumatic Stress Disorder (PTSD) Examination that indicates that the Veteran acknowledged that he was too ashamed to report the basis of his mental-health related military sexual trauma symptoms, but other symptoms included rectal bleeding and anal verruca. The medical opinion also failed to note a November 2015 written statement from the Veteran’s treating physician, which demonstrates the Veteran reported that during active service he was raped and sodomized hundreds of times and given that history, it is certainly plausible that the repeated trauma in that area could be responsible for the delay in symptoms that caused the Veteran to present with a more advanced stage diagnosis of poorly differentiated squamous cell carcinoma, basaloid type, of the anal canal. The written statement also provides that it is also possible given that the tumor is human papillomavirus positive, that the human papillomavirus could have been contracted during that time. A corresponding private treatment record notes that if the Veteran contracted human papillomavirus due to his sexual assault, then the development of anal cancer could be related to this incident. Additionally, the March 2016 medical opinion is also based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458 (1993) (a medical opinion based on an inaccurate factual premise is not probative). The March 2016 medical opinion advises that because the Veteran experienced sexual abuse prior to his active service, a determination as to when he contracted the human papillomavirus could not be made. However, while the evidence contained in the Veteran’s claims folder shows that he has a history of sexual abuse, it does not demonstrate that the he was raped or sodomized prior to his active service. Because the March 2016 VA medical opinion is inadequate, the Board cannot make a fully-informed decision on the issue of service connection for squamous cell carcinoma of the anal canal, to include as secondary to military sexual trauma. Therefore this matter must be remanded for an addendum medical opinion. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from June 2017 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 to adequately identify any physicians and/or facilities relating to his claim for service connection. Make two requests for the authorized records from any physicians and facilities adequately identified by the Veteran, unless it is clear after the first request that a second request would be futile. 3. After the above development is completed, obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s squamous cell carcinoma of the anal canal. (a.) The examiner must opine whether the Veteran’s squamous cell carcinoma of the anal canal is related to an in-service injury, event, or disease, including the Veteran’s military sexual trauma. In rendering the opinion, the clinician must discuss: (b.) The Veteran’s service treatment records that show evidence of treatment for anal warts. (c.) A January 2012 Initial Posttraumatic Stress Disorder (PTSD) Examination that indicates that the Veteran acknowledged that he was too ashamed to report the basis of his mental-health related military sexual trauma symptoms, but other symptoms included rectal bleeding and anal verruca. (d.) A November 2015 written statement from the Veteran’s treating physician, which demonstrates the Veteran reported that during active service he was raped and sodomized hundreds of times and given that history, it is certainly plausible that the repeated trauma in that area could be responsible for the delay in symptoms that caused the Veteran to present with a more advanced stage diagnosis of poorly differentiated squamous cell carcinoma, basaloid type, of the anal canal. The written statement also provides that it is also possible given that the tumor is human papillomavirus positive, that the human papillomavirus could have been contracted during that time. (e.) A November 2015 private treatment record that notes that if the Veteran contracted human papillomavirus due to his sexual assault, then the development of anal cancer could be related to this incident. (Continued on the next page) All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel