Citation Nr: 18155952
Decision Date: 12/06/18	Archive Date: 12/06/18

DOCKET NO. 17-00 578
DATE:	December 6, 2018
REMANDED
Entitlement to service connection for bladder cancer, claimed as secondary to service-connected prostate cancer, is remanded.
REASONS FOR REMAND
The appellant is a Veteran who served on active duty from May 1970 to January 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a January 2014 Department of Veterans Affairs (VA) rating decision.
The Veteran alleges radiation therapy used to treat his service-connected prostate cancer led to his development of bladder cancer. He received external beam radiation therapy (completed in February 2010). Bladder cancer was diagnosed in March 2013. 
There is conflicting medical opinion evidence in the record regarding the etiology of the Veteran’s bladder cancer. A May 2012 VA examiner (on the claim of service connection for bowel urgency due to the service-connected prostate cancer) opined that the bowel urgency is at least likely as not due to the Veteran’s prostate cancer. The examiner noted that current medical literature concludes that rectal irritation or rectal bleeding, frequent and painful urination, blood in the urine, possible rectal fistulas, secondary cancer development in the bladder or rectum as a result of the radiation therapy, fatigue, diarrhea, bowel urgency/leakage and sexual dysfunction are possible side effects of radiation therapy, including External Beam (IMRT, SBRT, IGRT) and Brachytherapy. [Service connection was granted for fecal urgency and incontinence as residuals of prostate cancer, effective April 2012.] A December 2013 urinary tract conditions VA examiner opined the Veteran’s bladder cancer is not caused by or a result of his prostate cancer. The examiner noted bladder cancer is associated with exposure to cancer-causing chemicals in tobacco, and other chemicals used in particular industries, and that the Veteran is a former smoker. The examiner opined there is no association between his residuals of treatment for prostate cancer (erectile dysfunction, urinary and fecal urgency, and incontinence) and bladder cancer.
In March 2014, the Veteran submitted an internet article that suggests a possible link between radiation therapy for treatment of prostate cancer and development of bladder cancer.
While the May 2012 examination did not address the etiology of bladder cancer (it had not yet been diagnosed), the opinion provided regarding side effects of radiation therapy cites to a relevant factor for consideration (and presents a medical question that is not adequately resolved by medical evidence in the record). A medical advisory opinion in the matter is necessary. 
The matter is REMANDED for the following:
Arrange for the Veteran’s record to be forwarded to an appropriate physician (such as an oncologist or urologist) for review and an advisory medical opinion regarding the likely etiology of his bladder cancer.  [If further examination of the Veteran is deemed necessary for the opinion sought, it should be arranged.]  Upon review of the record (and examination of the Veteran if needed), the consulting physician should provide responses to the following:
(a) Identify the likely etiology for the Veteran’s bladder cancer.  Specifically, is it at least as likely than not (a 50% or higher probability) that his prostate cancer (and radiation therapy he received for prostate cancer) was an etiological factor for his development of bladder cancer?
(b) If the response to (a) is no, is it at least likely as not (a 50% or higher probability) that the bladder condition is otherwise etiologically related to the Veteran’s active service? If not, please identify the etiology considered more likely. 
Include rationale with all opinions. The rationale should include comment addressing whether a history of smoking precludes that radiation therapy for prostate cancer may be a factor for the development of bladder cancer. Please include comment on (express agreement or disagreement with) the opinions by the May 2012 and December 2013 VA examiners.
 
GEORGE R. SENYK
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Naumovich, Associate Counsel