Citation Nr: 18155766 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 10-35 775 DATE: December 6, 2018 ORDER Entitlement to service connection for prostate cancer as a result of exposure to ionizing radiation is denied. Entitlement to service connection for erectile dysfunction (ED) is denied. Entitlement to service connection for a disability manifested by rectal bleeding, rectal incontinence, and colon damage, is denied. Entitlement to service connection for a disability manifested by urinary incontinence is denied. Entitlement to service connection for a precancerous growth on the esophagus, to include Barrett’s esophagus, a hiatal hernia and gastroesophageal efflux disease (GERD) as a result of exposure to ionizing radiation, is denied. FINDINGS OF FACT 1. The preponderance of the evidence reflects that the Veteran’s prostate cancer is not due to ionizing radiation exposure or any other incident of active service. 2. The preponderance of the evidence reflects that the Veteran’s ED was not incurred in service. 3. The preponderance of the evidence reflects that the Veteran’s disability manifested by rectal bleeding, rectal incontinence, and colon damage, was not incurred in service. 4. The preponderance of the evidence reflects that the Veteran’s disability manifested by urinary incontinence, was not incurred in service. 5. The preponderance of the evidence reflects that the Veteran’s precancerous growth on the esophagus, to include Barrett’s Esophagus, a hiatal hernia and GERD was not incurred in service. CONCLUSIONS OF LAW 1. The Veteran’s prostate cancer was not incurred in or aggravated by service; nor may it be presumed to be due to ionizing radiation exposure in service. 38 U.S.C. §§ 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (d), 3.311 (2018). 2. The Veteran’s ED was not incurred in or aggravated by service or any incidents therein. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 3. The Veteran’s disability, manifested by rectal bleeding, rectal incontinence, and colon damage was not incurred in or aggravated by service or any incidents therein. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 4. The Veteran’s disability manifested by urinary incontinence was not incurred in or aggravated by service or any incidents therein. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 5. The Veteran’s precancerous growth on the esophagus, to include Barrett’s esophagus, a hiatal hernia and GERD was not incurred in or aggravated by service or any incidents therein. 38 U.S.C. §§ 1116, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1956 to February 1958. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of February 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi which denied the benefits being sought. Jurisdiction currently lies with the St. Louis, Missouri RO. In May 2013, the issue of service connection for prostate cancer was remanded. The Board notes that the RO has substantially complied with the May 2013 remand directives. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The case has now been returned to the Board for further appellate action. In August 2017, the Veteran testified at a hearing before the undersigned. The record was held open for 60 days, to allow the Veteran to present additional evidence. A transcript of the hearing is of record. The Board notes that the Veteran’s service treatment (STRs) are not available and efforts to retrieve them have been unsuccessful. A VA memorandum on Formal Finding on the Unavailability of Complete Service Treatment Records and Personnel Records, dated in March 2009, indicates that they were unable to confirm radiation risk and record of exposure to radiation for the Veteran’s period of service in the Army from June 1, 1956, through February 21, 1958. Similarly, a VA Request for Information in July 2013 revealed that no records were found at Fort Huachuca. In cases where service treatment records are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board’s analysis of the Veteran’s claim has been undertaken with these heightened duties in mind. Neither the Veteran nor his attorney have raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303 (a), (b), 3.309 (a) (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d) (2018). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303 (2018); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a) (2018). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing before the aggravation. 38 C.F.R. § 3.310 (b) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). To establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence considering the entirety of the record. The standard of proof to be applied in decisions on claims for veterans’ benefits is outlined in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102 (2018). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). Service connection for a condition claimed as due to radiation exposure can be established in one of three ways: (1) by demonstrating that the condition at issue is one of the types of cancer that are presumptively service connected under 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309; (2) by demonstrating direct service connection under 38 C.F.R. § 3.303, a task that “includes the difficult burden of tracing causation to a condition or event during service,” Combee v. Brown, 34 1039, 1043 (Fed. Cir. 1994); or (3) by demonstrating direct service connection under 38 C.F.R. § 3.303, with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is one of the “radiogenic diseases” listed by the Secretary in § 3.311(b). Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff’d sub nom Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997). The term “radiation-exposed veteran” means a veteran who participated in a radiation-risk activity. 38 C.F.R. § 3.309 (d)(3)(i). The term “radiation-risk activity” includes onsite participation in a test involving the atmospheric detonation of a nuclear device, occupation of Hiroshima or Nagasaki, Japan by the United States from August 1945 to July 1946, internment as a prisoner of war in Japan during World War II, service of at least 250 days prior to February 1992 on the grounds of a gaseous diffusion plant located in Kentucky, Ohio, or Tennessee, or service in a capacity which would qualify the individual for inclusion as a member of the Special Exposure Cohort. 38 C.F.R. § 3.309 (d)(3)(ii) (2018). The Veteran contends that he developed prostate cancer, and residuals therefrom, including rectal bleeding, rectal incontinence, colon damage, ED, urinary incontinence, and a precancerous growth on the esophagus, to include Barrett’s esophagus, a hiatal hernia, and GERD, as a result of radiation exposure during service. Specifically, he contends that his exposure occurred in 1957 as a participant in Operation PLUMBBOB. The Board notes that Operation PLUMBBOB, an atmospheric nuclear test conducted at the Nevada Test Site, occurred during the period from May 28, 1957, through October 22, 1957. 38 C.F.R. § 3.309 (d)(3)(v)(N) (2018). The Veteran’s service personnel records show that he was a participant of Operation PLUMBBOB in 1957. Additionally, a letter dated January 14, 2010, from the Defense Threat Reduction Agency (DTRA) confirmed the Veteran’s participation in 1957. A memorandum dated January 2017 from the Director of Compensation Services to the Secretary of Health, also confirms the Veteran’s participant of Operation PLUMBBOB, in 1957. The Record shows that the Veteran was diagnosed with prostate cancer in 2003. Further, the Veteran acknowledged during his August 2017 hearing that he believed that it was in 2003 when he received the diagnosis. Regarding a grant of service connection on a presumptive basis, although prostate cancer is included in the list of “radiogenic” diseases under 38 C.F.R. § 3.311 (b), a presumption of service connection is not created. Rather, § 3.311 (b) affords the Veteran special processing of the claim, which “requires a case-by-case determination of service connection for each claim based on one of the listed diseases.” Ramey, 120 F.3d at 1245. Here, the January 2010 letter from the DTRA, as referenced above, also notes that a June 2006 Veteran’s Advisory Board on Dose Reconstruction meeting, established conservative theoretical maximum doses utilizing actual radiation level measurements and technical calculations from atmospheric nuclear test detonations, previously established prostate doses, bounding assumptions about exposure scenarios, and radiation science fundamentals. Therefore, based on the conservative theoretical maximum doses the Veteran could have received during his participation in Operation PLUMBBOB are not more than: External gamma dose: 16 rem; External neutron dose: 0.5 rem; Internal committed dose to the prostate (alpha): 0 rem; Internal committed dose to the prostate (beta + gamma): 1 rem. Additionally, a memorandum dated December 2016, regarding radiation exposure development, notes that the Veteran’s prostate cancer was diagnosed in August 2003 and the pathology indicated adenocarcinoma of the prostate, Gleason Scale 3+3=6. It also noted the Veteran’s history of elevated PSA levels. Further, the December 2016 memorandum notes that there was a second diagnosis of precancerous benign growth of the esophagus, due to exposure to ionizing radiation and a diagnosis of Barrett’s esophagus was provided. The March 2015 CAPRI records reveal hyperkeratotic lesions of the vocal cords, resulting in benign appearance. A January 2017 memorandum from the Director of Compensation Service to the Under Secretary of Health noted an August 2003 biopsy which confirmed prostate cancer and that the Veteran’s first exposure to ionizing radiation was at age 20. Further, the Veteran, a former pack-a-day cigarette smoker, quitting in 1983, had no familial history of cancer. Following service, he worked in the construction and warehousing trades with numerous companies to include the City of St. Louis. The memorandum also repeated the dose estimates provided by the DTRA. A February 2017 memorandum from the Director of Era Environmental Health Program to the Director, Compensation Service notes the Veteran’s service, post-service and medical history with prostate cancer. It also notes the dosage of radiation that the Veteran “could have” received while a participant in Operation PLUMBBOB. Moreover, it states that the Interactive Radio Epidemiological Program (IREP) of the National Institute of Occupational Safety and Health (NIOSH) was used to estimate the likelihood of the Veteran’s cancer and for calculation, the Veteran’s external radiation doses were assumed to have been received as a single acute dose in the earliest year of exposure (1957). The memorandum concludes that “it is our opinion that it is not likely that [the Veteran’s] prostate cancer was caused by exposure to ionizing radiation while in military service.” In support of his claims, the Veteran submitted two treatise documents: Atomic Veterans’ Newsletter, detailing the effects of ionizing radiation on Veterans, including some who served during atmospheric atom bomb tests conducted in Nevada in 1957. The second, Operation “PLUMBBOB” Feedback, by Tom Berg, notes that many of the military personnel who took part in the operation “are now deceased, the victims of a host of illnesses caused by their exposure to ionizing radiation.” Considering the above, including the Veteran’s contention, a VHA medical opinion was obtained in June 2018. The VHA physician, after a thorough review of the evidence of record, provided a negative opinion for each of the above-referenced disabilities. The Board finds the opinion most probative against a finding of service connection for each of the Veteran’s claims. A. Service connection for prostate cancer is denied Regarding prostate cancer, the physician opined that “based on the data presented, and the reliance on the IREP and NIOSH-IREP and the DTRA adjusted total doses of ionizing radiation to the prostate, the Veteran’s prostate cancer was not likely to have been caused by his ionizing radiation exposure at the Nevada Testing Site.” The physician explained that per the Veteran’s Radiation Worksheet, he witnessed FOUR tests, both in the open and in the trenches and reported he was 10 miles and [one] mile from ground zero… [Additionally,] research [shows that] during Operation PLUMBBOB, it was Army policy that individuals stationed at CDR be afforded the opportunity to observe at least one nuclear test: Personnel may have observed more than one test detonation, but it would have been from a distant location at which any radiation dose would have been significant. Regarding radiation treatment for his prostate cancer, the physician noted that the Veteran did not receive radiation treatments at the Nevada Testing Site. Rather, “he received an order of 40-45 treatments of radiation to TREAT his prostate cancer between November 2003-January 2004.” He further noted that “[m]ultiple progress notes after his treatment state that he had no gastrointestinal (GI) complaints, nausea, vomiting, and diarrhea. He did develop rectal bleeding after the radiation therapy, for which colonoscopy was done [and] which showed radiation telangiectasias and hemorrhoids most likely the cause of bleeding.” The Veteran testified that during his hearing that his prostate cancer was caused when during one of the blasts he was told to turn his back away, pull his coat over his head and close his eyes tight. He also testified that during testing, he was wearing regular clothes, and bent over, with his buttocks facing the blast. Soon after, he experienced bleeding from the rectum, due to the prostate cancer. In addressing the Veteran’s testimony, the physician stated that the prostate is autonomically not located in the anus. “Also, the fact that he was turned away from ground zero has no bearing on radiation penetration. In fact, alpha and beta particles are often stopped by clothing and skin. Gamma radiation and neutron radiation are the most penetrating, but even with his maximum estimated exposure of 16 rem, his committed dose of radiation to the prostate was only 1 rem. Symptoms of radiation exposure are many times not manifest until much higher doses close to 100 rem. In comparison, the average member of the general public in the U. S. receives a background radiation dose (natural and artificial) of approximately 0.36 rem per year.” Additionally, the physician added that other data does not support such a position. For example: Memorandum dated 21, December 2006 from Chief Public Health and Environmental Hazards Officer provided instructions for expedited methodology processing using worse case dose case assessment from DTRA. The adjusted total prostate dose for Nevada Test Site participants cases [was] less than the applicable screening doses and [was] therefore unlikely to be due to exposure to ionizing radiation during military service. VA radiogenic disease compensation decisions are now based on Internet-accessible software that determines the probability of causation (PC) for a disease based on occupational radiation exposure, the Interactive Radio-Epidemiological (IREP) software. The IREP is a computer code developed at the request of the National Cancer Institute (NCI) as part of the effort to update 1985 Radio-epidemiological Tables. Using the interactive program, it was determined that the Veteran’s probability of causation with the maximum radiation he could have been exposed to, based on the reconstruction data was 19.79 [percent] which is well below the 50 [percent] probability that would be needed to establish service connection. [Further,] the American Cancer Society (ACS) and the National Cancer Institute (NCI) report the lifetime risk for developing any kind of cancer for members of the U. S. general population to be greater than 40 percent. The lifetime risk is almost 45 percent for males. Regarding the articles submitted by the Veteran, the physician stated that he was unable to scientifically use them as anecdotal testimony as fact with no objective, and evidence-based studies [as] support. B. A disability to include rectal bleeding, rectal and urinary incontinence, colon damage, and ED is denied The VA physician concluded that it was not likely that the Veteran’s colon damage, rectal bleeding, rectal incontinence, and ED would have been caused by the dose of ionizing radiation that the Veteran was exposed to in Operation PLUMBBOB in 1957. These disabilities, he deduced, are most likely caused by his radiation treatment for prostate cancer. In arriving at his conclusion, the physician noted that the Veteran testified that he was hospitalized after one of the nuclear tests for rectal bleeding. Also, he testified that he had ED, rectal discharge, and rectal bleeding since his radiation exposure. However, he presented no records of treatment to corroborate his testimony. Additionally, there is no mention in his VA medical record of diarrhea, abdominal discomfort (outside of his gastroesophageal reflux) rectal discharge or bleeding until AFTER his treatment for prostate cancer. In fact, his initial history and physical in Primary Care states in the review of symptoms: “denied GERD, heartburn, reflux, constipation, diarrhea, use of laxative stimulants, antidiarrheal agents, denies a history of GI bleed, last EGD and colonoscopy was: colonoscopy never had, denies family history of GI cancer” and his October 2003 appointment review of symptoms stated: denied any GI symptoms secondary to melena reflux, heartburn, hematemesis nausea/vomiting/diarrhea. His GI physical exam was also unremarkable. It was not until March 2004 after his radiation treatment was completed that he complained of rectal bleeding. His initial appointment with GI, presumably to discuss his reflux and be evaluated for a colonoscopy stated: [March 2, 2004] referred to GI for blood in the stool. He has no LGI (lower gastrointestinal complaints) … Endoscopy diagnosis of September 2004 [revealed] sigmoid diverticulosis, mild internal hemorrhoids, otherwise normal colonoscopy, with slightly limited sensitivity for small polyps by retained stools. At this time there was no radiation-induced colitis. Also with his previous complaints for years of rectal discharge and bleeding, there were no abnormal findings on the colonoscopy except hemorrhoids, which they felt was the most likely cause of the bleeding on the toilet paper. With the essentially normal first colonoscopy, there was no evidence that his symptoms would have been caused by his exposure to ionizing radiation. Regarding the rectal bleeding, rectal incontinence, colon damage, urinary incontinence, and ED, the physician noted that they could all be residuals effects of radiation treatment for prostate cancer. Regarding the rectal bleeding, the physician specifically noted that “[i]n fact, the [Veteran] did develop bright red blood per rectum and had a subsequent colonoscopy that showed radiation telangiectasia, av [arteriovenous] malformation and hemorrhoids along with mild radiation proctitis. [However,] this radiation inducted proctitis was NOT caused by his exposure in 1957 during Operation PLUMBBOB.” The physician also noted that the Veteran was known to have BPH [benign prostatic hyperplasia] which is a cause of ED. “He did have ED on presentation to primary care clinic, but there is no documentation that he was ever treated for this soon after exposure in 1957 [and] it would be mere speculation that his ED occurred as a result of his exposure to ionizing radiation during his military service.” The physician concluded that it is not likely that his colon damage, rectal bleeding, rectal incontinence, and ED would have been caused by the dose of ionizing radiation he was exposed to in Operation PLUMBBOB in 1957. It was most likely caused by his radiation treatment for prostate cancer because of evidence of a normal colonoscopy, with no colon damage, rectal bleeding and rectal incontinence. C. A precancerous growth on the esophagus, to include Barrett’s esophagus, a hiatal hernia, and GERD is denied Per the medical opinion of June 2018, the Veteran’s Barrett’s Esophagus, a hiatal hernia, and GERD are not likely caused by his exposure to ionizing radiation during his period of military service. The physician explained that “ Barrett’s Esophagus is caused by chronic reflux, [which] is not induced by ionizing radiation with the data that was presented in the [Veteran’s] c-file. Barrett’s Esophagus is also not a malignant lesion. In the small percentage of patients (around 2.4 percent) [who] develop malignancy, it is almost always Adenocarcinoma. Radiation-induced esophageal malignancy is almost always Squamous Cell Carcinoma. Ionizing radiation also does not cause Barrett’s Esophagus, a precancerous growth. Barrett’s Esophagus is believed to be caused by chronic reflux and esophagitis due to that reflux. The esophageal mucosa through chronic irritation transforms (a process called metaplasia) to abnormal cells with the potential to become dysplastic and eventually malignancy. The malignancy is almost always Adenocarcinoma. Radiation-induced malignancy is almost always Squamous Cell Carcinoma. Radiation does not cause Barrett’s Esophagus; reflux does. The [Veteran] has had multiple upper endoscopies over the years. The initial endoscopy was normal; a subsequent endoscopy showed short segment Barrett’s Esophagus. The [Veteran testified at his hearing] that he thought the Barrett’s Esophagus was related to radiation because his prostate cancer was. His lay interpretation was “cancer spreads.” He is correct that many cancers do metastasize, but the type of metastasis is dependent on the originating tissue. Prostate Adenocarcinoma does not spread to the esophagus causing Barrett’s Esophagus. This is fundamentally incorrect with no scientific basis for the [Veteran’s] comments. The last biopsy of February 2010 revealed mild chronic inflammation, negative for malignancy, dysplasia or metaplasia. With treatment, his Barrett’s Esophagus was resolved. I am unaware of any further endoscopies or biopsies that may have shown a recurrence. Regarding GERD, the physician explained that it is a common disorder, and “is not caused by ionizing radiation, but rather incompetence (or in this case, a hiatal hernia) in the esophageal sphincter. High doses of radiation can cause esophagitis, but in this Veteran’s case, endoscopy reveals reflux-induced esophagitis.” Analysis Based on the evidence presented above, the Board finds that service connection is not warranted for prostate cancer, a disability manifested by rectal bleeding, rectal incontinence, and colon damage, a disability manifested by urinary incontinence, and a precancerous growth on the esophagus, to include Barrett’s Esophagus, a hiatal hernia and GERD. First, regarding prostate cancer, the Veteran does not assert any other in-service event, injury or disease, but for his radiation exposure as a participant in 1957 in Operation PLUMBBOB at the Nevada Test Site. The record shows that the Veteran was diagnosed with prostate cancer in 2003. Before that, there were no recorded symptomologies of his prostate cancer. In fact, he acknowledged during his August 2017 hearing that he believed that it was in 2003 when he received the diagnosis. There was no mention of experiencing the continuation of symptoms from 1957, to when he was diagnosed. As such, the continuity of symptomatology is not applicable on a direct basis or as a chronic disease. 38 C.F.R. §§ 3.303, 3.303(b), 3.307, 3.309 (2018). Regarding presumptive service connection under 38 C.F.R. § 3.311, the June 2018 VHA physician found no nexus between the Veteran’s prostate cancer and his radiation exposure in service. In rendering his competent medical opinion, the physician addressed the December 2006 Memorandum from the Chief Public Health and Environmental Hazards Officer, the DTRA data, and the IREP, and post-service treatment records. He also cited research to support his position. Service connection for a disability, manifested by rectal bleeding, rectal incontinence, colon damage, ED and a disability manifested by urinary incontinence, is also not warranted, either on a direct or secondary basis. The June 2018 VHA physician found a negative nexus to the Veteran’s ionizing radiation exposure. The physician noted that they are all residuals of the radiation treatment the Veteran received for his prostate cancer in 2003 and 2004, and there was no evidence of record of such issues before. Specifically addressing the Veteran’s contention of the continuation of ED and rectal bleeding since his exposure in 1957, the physician noted the evidence of record showed normal initial colonoscopy and no colon damage, rectal bleeding, and rectal incontinence that would have been caused by his exposure to ionizing radiation. As for the ED, the physician stated that the Veteran was known to have BPH which causes ED. However, there is no documentation that he was ever treated for this soon after exposure in 1957. Since the physician found no link between the Veteran’s ED, rectal bleeding, rectal incontinence, colon damage, and urinary incontinence to service, service connection on a direct basis is not warranted. The physician however noted that these disabilities were due rather to his prostate cancer and the radiation he received for its treatment. However, since service connection is herein denied for prostate cancer, the second Wallin element is not met, and service connection on a secondary basis for these disabilities must be denied. Service connection for a disability, manifested by a precancerous growth on the esophagus, to include Barrett’s Esophagus, a hiatal hernia and GERD is not warranted. The medical opinion of June 2018, noted that Barrett’s Esophagus, a precancerous growth, is caused by chronic reflux and is not a malignant lesion, due to ionizing radiation. The Veteran’s initial endoscopy was reported as normal. Regarding GERD, the physician explained that is not caused by ionizing radiation, but rather a hiatal hernia and the endoscopy revealed reflux-induced esophagitis. The Board acknowledges that the Veteran is competent to report on his observable events during Operation PLUMBBOB in 1957 or his prostate, rectal bleeding, ED, urinary and rectal incontinence symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994). His statements relating to his symptoms are credible. Whether the Veteran’s Barrett’s Esophagus, hiatal hernia, GERD, prostate cancer and residuals therefrom (rectal bleeding, and urinary and rectal incontinence), are related to his in-service radiation exposure, falls outside the realm of common knowledge of the Veteran in this case. Determining the etiology of these disabilities requires medical inquiry into biological processes, anatomical relationships, physiological functioning, and the impact of radiation on the body. Such internal physical processes are not readily observable and are not within the competence of the Veteran, who in this case, has not been shown by the evidence of record to have the training, experience, or skills needed to provide a competent etiology opinion. Although he is competent to report the persistence of his observable symptoms, he is not competent to provide a link to his exposure to ionizing radiation and the symptoms he experiences. As a result, his lay opinion is not competent evidence and is not more probative than that of the June 2018 VHA physician. Again, the Board finds the physician’s opinion to be highly persuasive evidence weighing against a nexus to the confirmed in-service radiation exposure. The Veteran does not allege any other in-service event but for the radiation exposure in 1957 from his participation in Operation PLUMBBOB at the Nevada Test Site. The medical evidence of record shows that the Veteran was diagnosed with prostate cancer in 2003, many years after service. Although during his hearing testimony, he indicated that his VA doctor who treated him and who has since left the VA, told him that his prostate cancer was attributable to his in-service radiation exposure. Even assuming that the Veteran is a reliable historian and accurately asserts that such an opinion was provided, because it is not of record, the Board cannot assess the probative value of such a medical opinion. Specifically, the Board is unable to determine the factual basis or rationale supporting the reported opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran’s report that his physician provided a favorable opinion carries little probative weight and is not sufficiently persuasive to outweigh the findings of the VHA medical opinion of June 2018. The Board affords the treatise evidence submitted in March and April 2010 less probative weight than the findings of the VHA physician. Generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The exception to this competency rule is when the medical treatise information, where “standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Wallin, 11 Vet. App. at 513. The article titled Operation “PLUMBBOB” Feedback provides a description of the nuclear tests conducted, including that some observers were told to face away from the blasts to avoid being blinded. The article stated that several thousand people had died snice the tests that were “victims to a host of illnesses caused by their exposure to ionizing radiation.” One veteran was quoted as saying that he had prostate cancer. Standing alone, this article does not support plausible causality. It does not address whether prostate cancer is related to radiation other than to quote a veteran who stated that he had the condition. It is mostly a summary of the testing, with anecdotal descriptions of what people saw during the tests. The article does not relate to the specific situation of the Veteran in this case. (Continued on the next page)   Regarding the Atomic Veterans’ Newsletter, this treatise describes nuclear testing over the years, including in Nevada. It contains anecdotal discussion of how some people died of illness following the exposure, and opined that soldiers were treated like “guinea pigs.” The article stated that radiation from the testing caused cancer among veterans. The article also contained letters from Veterans who believed their illnesses were due to radiation. Some of them discussed how their claims were denied by VA. This treatise does not relate to the specific situation of the Veteran. The statement that radiation exposure from nuclear testing can cause cancer is generic. It is less probative than the VHA physician’s opinion. He reviewed the claims file, including dose estimates and other evidence specific to the Veteran in this case, and used this information as the basis for his opinion. As the most probative evidence does not show that the Veteran’s Barrett’s Esophagus, hiatal hernia, GERD, prostate cancer, and residuals therefrom are due to exposure to ionizing radiation, the preponderance of the evidence is against his claims. The claims, therefore, must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Stevens, Associate Counsel