Citation Nr: 18155479 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 17-14 603 DATE: December 4, 2018 ORDER Entitlement to service connection for gastrointestinal stomal tumor (GIST) of the stomach, liver, lungs, and bowel is denied. FINDING OF FACT The Veteran GIST was not shown in service or for many years thereafter, and it is not due to exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for GIST of the stomach, liver, lungs, and bowel have not been met. 38 U.S.C. §§1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the U.S. Army from November 1966 to October 1969; he had service in the Republic of Vietnam. Entitlement to service connection for GIST of the stomach, liver, lungs, and bowel, to include as due to herbicide agent exposure or secondary to prostate cancer. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310. Moreover, where a veteran served continuously for 90 days or more and cancer becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a). As an initial matter, the medical evidence of record shows the Veteran is diagnosed with GIST. Thus, the first criteria for service connection has been met. The question now becomes whether that condition is related to service. The Veteran asserts that his GIST is due to exposure to Agent Orange or secondary to his service connected prostate cancer. The Veteran’s service personnel records show that he served in Vietnam from April 1967 to April 1968, and is therefore presumed to have been exposed to Agent Orange. The Veteran has argued that his GIST is a type of soft tissue sarcoma, which is listed as a presumptive condition under 38 C.F.R. § 3.309. In August 2015, a VA physician opined that the Veteran had a gastrointestinal (GI) tumor, which had an association with Agent Orange exposure. The physician provided no rationale for this opinion. In January 2016, a VA examiner provided an opinion addressing whether the Veteran’s GIST was secondary to his service-connected prostate cancer. The examiner opined that the GIST was less likely as not caused by or a result of prostate cancer because the Veteran’s GIST predated his prostate cancer, and there is no correlation of metastatic disease associated with the two conditions. A VA compensation and pension examiner provided a negative opinion in April 2017 and indicated the private physician’s opinion was based on outdated speculation. The examiner noted that GI stromal tumors are not related to sarcoma or Agent Orange exposure. Specifically, he stated that: “After review of this veteran’s records, including the anatomical pathology report, it is clear this is a stromal tumor, benign of mesenchymal origen [sic] and unrelated to any sarcoma. Before 1990 some pathologists suggested a relationship to either muscle or nerve cells, but his hypothesis has been disproven by genetic testing and the finding of the KIT gene expression in GI stromal tumors, not seen in sarcoma.” The Board finds the April 2017 opinion more probative as it is based on updated medical studies and provided a complete rationale, whereas the August 2015 opinion merely provided a one-sentence conclusion. Moreover, the Veteran’s cancer was first diagnosed in 2002, decades after his discharge from service. Accordingly, service connection on a presumptive basis both as due to herbicide exposure and as a chronic condition is also not warranted. 38 C.F.R. § 3.309(a). Even though presumptive service connection is not warranted, the Veteran is not precluded from establishing service connection for GIST with proof of direct causation. Combee v. Brown, 34 F.3d (Fed Cir. 1994). However, the Veteran does not contend and the evidence does not reflect that his stomach cancer arose during service or is related to service for reasons other than his claimed exposures discussed above. The Board acknowledges that the Veteran receives treatment for his disabilities, including his GIST through VA and private treatment providers. Private treatment records confirm the Veteran’s diagnosis of, and treatment for GIST. The VA treatment records have also confirmed on-going management and surveillance for subsequent malignancies following complete resection of the tumor. However, the VA and private treatment records are silent as to any nexus regarding a correlation between the Veteran’s GIST and his active service. Although the Veteran believes that his disability is related to service, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion. In this regard, the etiology of cancer is a matter that requires medical training and expertise to determine. Accordingly, his opinion as to the diagnosis or etiology of his GIST is not competent medical evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, the Board finds the April 2017 opinion of the VA examiner to be significantly more probative than the Veteran’s lay assertions. Moreover, secondary service connection requires a nexus between the Veteran’s claimed condition and an already service-connected disability. Although the Veteran is service connected for prostate cancer, the most credible and competent evidence of record, the January 2016 VA opinion, indicates there is no connection between the Veteran’s GIST diagnosis and prostate cancer. Again, an opinion provided by a medical physician with the appropriate skills and experience is considered more probative than the Veteran’s lay statements. In sum, the competent and probative evidence is against a finding that the Veteran’s GIST is related to service, to include his conceded exposure to Agent Orange, or secondary to his prostate cancer, and service connection must be denied. The Board is sympathetic to the Veteran’s claim, but without a competent and credible opinion either linking his GIST to service (including herbicide exposure) or secondary to a service-connected disability, his claim cannot be granted. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Price, Associate Counsel