Citation Nr: 18156333 Decision Date: 12/11/18 Archive Date: 12/07/18 DOCKET NO. 05-37 934 DATE: December 11, 2018 ORDER Entitlement to service connection for the cause of the Veteran’s death is denied. FINDING OF FACT 1. The Veteran died in November 2004. The Death Certificate lists the cause of death as generalized carcinomatosis due to metastatic cancer to the liver from an unknown primary site. 2. At the time of his death, the Veteran did not have any service-connected disabilities. 3. The competent evidence does not demonstrate that the Veteran’s death was related to either herbicide exposure or any other incident of active service. CONCLUSION OF LAW The criteria for entitlement to service connection for the cause of the Veteran’s death have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 1310 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.312 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran’s active service included a tour in the Republic of Vietnam (RVN); hence, the appellant’s assertion that his fatal cancer was due to his presumed exposure to herbicide agents while there. Two prior Board decisions (03/18/2009 BVA; 10/28/2016 BVA) denied the appeal, both of which were vacated and remanded by the Court of Appeals for Veterans Appeals (Court) pursuant to Joint Motions for Remands (JMR). As discussed in the decision below, the bases of the JMRs have been fully addressed by Board remands, the most recent of which were to ensure the VA examiner considered the medical literature cited by the appellant. See 11/28/2017 BVA Remand; 07/31/2018 BVA Decision) The most recent remand addressed the final facet of the bases that the parties agreed to in the JMR. See id. 1. Entitlement to service connection for the cause of death Legal Requirements Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Where there is a chronic disease shown as such in service or within the presumptive period under 38 C.F.R. § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for disease that is diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303(d). The Court has held that, in order to prevail on the issue of service connection, 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 evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). In order for service connection for the cause of a Veteran’s death to be granted, it must be shown that a service-connected disability caused the death, or substantially or materially contributed to cause death. A service-connected disability is one that was incurred in or aggravated by active service, one that may be presumed to have been incurred during such service, or one that was proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.312. When it is determined that a Veteran’s death was service connected, his surviving spouse is generally entitled to dependency and indemnity compensation (DIC). See 38 U.S.C. § 101. The death of a Veteran will be considered as having been due to a service-connected disability when such disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). The service-connected disability will be considered the principal (primary) cause of death when such disability, either singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). The service-connected disability will be considered a contributory cause of death when it contributed so substantially or materially to death that it combined to cause death, or aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1). The debilitating effects of a service-connected disability must have made the decedent materially less capable of resisting the fatal disease or must have had a material influence in accelerating death. See Lathan v. Brown, 7 Vet. App. 359 (1995). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In such a situation, however, it would not generally be reasonable to hold that a service connected disability accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(3), (4). In certain cases, service connection can be presumed if a Veteran was exposed to an herbicide agent during active service. Presumptive service connection is warranted for the following disorders: chloracne or other acneform disease consistent with chloracne; Type II diabetes; Hodgkin’s disease; multiple myeloma; non-Hodgkin’s lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and, soft-tissue sarcoma (other than ostrosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). Presumptive service connection for these disorders as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). The governing law provides that a “Veteran who, during active military, naval, or air service, served in RVN 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 U.S.C. § 1116(f). The Secretary, under the authority of the Agent Orange Act of 1991 and based on medical studies, has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-08 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007). When a disease is first diagnosed after service but not within an applicable presumptive period, service connection may nevertheless be established by evidence demonstrating that disease was in fact incurred during service. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). If there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Combee at 1043-44. It is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of held that an appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. The Court has also stated, “It is clear that to deny a claim on its merits, the evidence must preponderate against the claim.” Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Discussion In the present case, the appellant asserts that Agent Orange exposure led to the Veteran’s death. Specifically, in her November 2005 VA Form 9, the appellant asserted that the Veteran had prostate cancer, and that it metastasized to the liver, which in turn ultimately caused the Veteran’s death. It was also asserted that the prostate cancer was due to his service in RVN. The Veteran died in November 2004, and his Death Certificate lists the cause of death as generalized carcinomatosis, with metastatic cancer to the liver from an unknown primary site. See 11/[redacted]/2004 Death Certificate. Thus, the question before the Board is whether the Veteran’s generalized carcinomatosis with metastases to the liver was causally related to his military service. The Board has first considered whether a grant of presumptive service connection is warranted under 38 C.F.R. § 3.309(e), for herbicide exposure. In this regard, there is no dispute as to the Veteran’s service in RVN during the requisite period set forth under 38 C.F.R. § 3.307(a)(6). However, presumptive service connection is only allowed for the diseases listed at 38 C.F.R. § 3.309(e). The Veteran in this case had metastatic cancer of the liver, which is not one of the diseases specified in section 3.309(e), for diseases specific to herbicide-exposed Veterans. However, the claimant contends that her husband had prostate cancer that metastasized to the liver, and prostate cancer is one of the diseases specified in section 3.309(e). Thus, she asserts, the Veteran’s death was ultimately caused by a disease related to herbicide exposure. Therefore, the Board will consider whether the Veteran had a diagnosis of prostate cancer. The Veteran’s service treatment records (STRs) are negative for any manifestation of prostate problems. Indeed, the retirement physical examination report specifically states that the prostate is within normal limits. See 03/04/2005 STR-Medical, 3rd Entry, P. 121. The STRs also do not reveal any liver problems or diagnoses of any type of cancer. Following separation from service in 1972, the Veteran had blood work done at a VA Medical Center (VAMC) in August 2003 that showed an elevated prostate specific antigen (PSA) level of 5.4. See 06/09/2005 Medical Treatment-Government Facility, 2nd Entry, P. 13. In November 2003, several months later, the doctor discussed the possibility of prostate cancer with the Veteran and recommended a prostate biopsy. The doctor did not diagnose prostate cancer at that time, but rather assessed PSA elevation. Id., P. 7. A note from the VAMC dated in January 2004 indicates that the Veteran did not wish to have a prostate biopsy, even after the doctor told the Veteran that without it, they would not be able to detect prostate cancer. Id., P. 1. In October 2004, VAMC records show that the Veteran had a CT scan of the abdomen, which showed extensive liver metastatic disease (12/15/04 Government Facility). A liver biopsy was performed at a non-VA medical center and the tissue was positive for malignancy and findings compatible with adenocarcinoma (03/04/2005 Government Facility P. 3). VAMC notes indicate the Veteran was referred to Dr. P. V. for follow-up (Id., P. 4). In early November 2004, Dr. P. V. admitted the Veteran to a hospital. He was assessed with metastatic cancer to the liver “most likely from colon or stomach.” He recommended a bone scan for metastases, with x-rays where metastases were found (09/09/2014 Non-Government Facility, P. 7-9). In another November 2004 record, Dr. P.V. stated that the “cancer is related to service.” The following day, a CT of the abdomen revealed diffuse metastatic liver disease with multiple masses in the right and left lobe. Examination of the prostate revealed extensive calcifications in the central zone with no peripheral masses identified. A bone scan revealed increased uptake in the superior right scapular area, indicating metastatic disease. It was recommended that the findings be confirmed by an MRI. The Veteran passed away shortly after these tests were completed (Id., P. 55-59). Following the Veteran’s death, several opinions were rendered as to the primary site of the metastatic liver disease. Dr. P. V. wrote a letter dated in April 2005 stating that he first saw the Veteran in October 2004 after he was referred to him by a doctor from the VAMC. He told the Veteran that expected survival for his type of disease-metastatic cancer to the liver from unknown primary-was less than 6 months. (08/23/2013 Non-Government Facility). Next, Dr. P. V. authored a letter in February 2006, in which he opined that, after reviewing the Veteran’s records, the Veteran’s liver cancer originated either in the prostate gland or the colon, and that he strongly believed this type of cancer was related to Agent Orange exposure. He stated that while he initially indicated the liver cancer was from an unknown primary, subsequent review of records led him to believe that the tumor started in the prostate gland given the elevated PSA level. However, the doctor followed that opinion by stating the other possibility was that the cancer originated in the colon, since most cancerous lesions of the liver originate in the colon (08/23/2013 Non-Government Facility). In August 2006, Dr. P. V. wrote that he had intended to have a bone scan done to document the presence of metastatic cancer, but the Veteran passed away before the scan could be done. Thus, although Dr. P. V. states there is no 100% scientific proof, his clinical suspicion was very strong and that suspicion should be sufficient upon which to grant VA benefits to the Veteran’s family (Id.). Finally, in June 2008, Dr. P. V. stated that, based on his clinical observation, the Veteran had prostate cancer that was service-related and which also contributed to his death. Since the Veteran’s PSA was abnormal, it was more likely than not that he had prostate cancer (03/16/2012 Third Party Correspondence, 4th Entry). The RO obtained a VA opinion in March 2006. The examiner reviewed the Veteran’s claims file, including medical records and radiological and laboratory reports. He opined that it was less likely than not that the Veteran’s prostate gland was the primary site of the cancer with metastasis to the liver and ultimately caused the Veteran’s death. He cited to the November 2004 ultrasound of the prostate that showed calcification but no masses or abnormalities. He opined that the Veteran did not have prostate cancer, but rather, that the elevated PSA was more likely secondary to the prostate calcification and inflammation. Additionally, colonic morphology tissue was found in the liver biopsy, indicating the most likely source of the liver cancer was the colon. Finally, the examiner stated that prostate cancer typically metastasizes to large bones, and there was no evidence of this in the Veteran’s case. Rather, there was probable metastasis to the scapula, which is a smaller bone (03/09/2006 VA Examination). The RO obtained another VA opinion in October 2011 (10/06/2011 VA Examination). The examiner reviewed the claims file, including medical records and radiological and laboratory reports. She also reviewed the statements from Dr. P.V. She noted that there were many statements by Dr. P.V. that the Veteran’s cancer and metastases to liver were secondary to the prostate. However, she noted that in none of the statements was there conclusive evidence to support these statements. Instead, she noted that there were multiple progress notes stating that the Veteran had positive occult blood in feces but never hematuria. She noted that the biopsy of the liver reported adenocarcinoma and that the primary was colonic. She explained that the occult blood is mostly frequently seen in colonic cancer and hematuria is most frequently seen in prostate cancer. The October 2011 VA doctor opined that it was less likely than not that the Veteran’s cause of death was the result of prostate cancer. She noted all the statements and the progress notes and procedures labs that the Veteran had during this time; and found that the Veteran had a liver biopsy that was suggestive of colon cancer metastasis. She stated that one of the primary organs in which the colon cancer metastases is the liver. In contrast, in prostate cancer, the primary organ is regional and distant bones (pelvis vertebra long bones). There were no comments related to possible bone metastases. The October 2011 VA doctor rendered an addendum opinion in October 2014 (10/09/2014 C&P Exam). The examiner once again stated that the Veteran’s elevated PSA was more likely secondary to the prostate calcification and inflammation. She noted that colonic morphology tissue was found in the liver biopsy. She stated that prostate cancer typically metastasizes to large bones and there was no evidence of this in the Veteran’s case. Rather, there was probable metastasis to the scapula, which is a smaller bone. Concerning Dr. P.V.’s opinion that the Veteran’s cancer was due to Agent Orange exposure, the October 2011 VA examiner noted that the following conditions are presumptively related to exposure to herbicides: chloracne, DM II, Hodgkin’s/non-Hodgkin’s disease, multiple myeloma, lymphoma, acute and subacute peripheral neuropathy, porphyria, prostate cancer, respiratory cancers (lung, bronchus, larynx or trachea) and soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). She noted that the Veteran was not diagnosed with any of those conditions. Moreover, she noted that although there was a statement by Dr. P.V. that the Veteran had prostate cancer, the only basis for this diagnosis was an elevated PSA. The October 2011 VA examiner explained that PSA levels generally increase as men age. She also noted that the Veteran was 70 years old when he was noted to have an elevated PSA of 5.0 (06/09/2005 Government Facility, P. 11). Five months later it was 5.4 ng/ml). She cited a Journal of Urology study regarding upper limits for PSA for various age groups. She noted that in November 2003, the Veteran was evaluated by the urologist and the findings on physical examination was more consistent with a benign prostate (Grade 1 enlarged prostate with smooth surface, no tenderness, no nodules and firm consistency). She also noted that the November 2004 ultrasound of the prostate which showed calcification but no masses or abnormalities of the prostate would favor a benign not a malignant condition. The JMR required that the VA examiner comment on the medical literature submitted by the Veteran, and the Board remanded to obtain compliance and for an opinion on whether colon cancer was involved and, if so, to what effect (06/05/2015 BVA Decision). In June 2015, the examiner submitted another addendum opinion in which she acknowledged the medical treatises put forth by the Veteran. She noted that attachment A was Dr. P.V.’s credentials; attachment B mainly reported on accuracy of cancer death certificates and its effect on cancer on cancer mortality statistics; attachment C merely affirmed what conditions were and were not considered presumptive conditions from herbicide exposure; attachment E reported the occurrence of liver cancer- either from Viral infections or Dioxin exposure; and attachment F also reported on liver cancer. She noted that liver cancer is not one of the presumptive conditions. With regard to the Veteran’s case, he did not have primary liver cancer; he had metastatic (secondary) liver cancer. She noted that attachment G was a Report to the Secretary of the Dept. of Veterans Affairs on the Association between Adverse Health Effects and Exposure to Agent Orange. She referred to the list of presumptive conditions. She had no argument against attachment H insofar as it only reported on approval of soft tissue sarcomas as a presumptive condition from herbicide exposure. The October 2011 VA examiner submitted an addendum in September 2015 (09/08/2015 C&P Exam) in which she once again noted that the Veteran was not diagnosed with prostate cancer when he underwent admission in 2004 and was found to have liver metastatic lesions. She pointed out that Dr. P.V.’s own admission and discharge note provided a final diagnosis in November 2004 of “Generalized carcinomatosis from metastatic cancer to the liver from unknown primary (Possibility of colon cancer as the primary but a colonoscopy was not done).” She stated that the studies at the time of evaluation were not consistent with a diagnosis of prostate cancer. She stated that the ultrasound showing extensive calcifications in the central zone with no peripheral masses identified and CT of the pelvis showing prostatic enlargement with calcifications and no pelvic masses or lymphadenopathy favored a benign not malignant condition in the prostate. She once again noted that elevated PSA levels are consistent with the Veteran’s age at the time and was consistent with a benign prostate. The Board notes that the crux of the case is whether the Veteran’s death was due to prostate cancer, which would be presumed to be service connected, given his exposure to herbicide agents. As set forth above, VA examiners have rendered opinions, including addenda to those opinions, that weigh against the claim; and, Dr. P.V. has submitted correspondences which weigh in favor of the claim. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional’s opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician’s special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. There are substantial and significant factors which favor the valuation of the VA medical opinions over the opinions of Dr. P.V. in this case. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). The Board finds that the evidence is in relative equipoise concerning the first two factors. All opinions were rendered with a full understanding of the Veteran’s factual premises. Further, all of the opinions were unequivocal. It is the third factor which renders the VA opinions far more probative. The Board notes that there are some internal inconsistencies in Dr. P.V.’s own opinion. As the VA examiners noted, when the Veteran died, Dr. P.V. listed the cause of death as generalized carcinomatosis, with metastatic cancer to the liver from “an unknown primary site.” The Board notes that the Veteran had an elevated PSA in August 2003, and that several months later (November 2003), the Veteran’s doctor discussed the possibility of prostate cancer with the Veteran and recommended a prostate biopsy. He did not diagnose prostate cancer at that time, but rather assessed PSA elevation. Consequently, at the time Dr. P.V. completed the death certificate, he was aware that prostate cancer was a possibility but did not list it on the death certificate. Even more telling, however, is that in November 2004, when the Veteran was admitted to a non-VA hospital, he was assessed with metastatic cancer to the liver “most likely from colon or stomach.” In Dr. P.V.’s April 2005 correspondence, he still referred to the Veteran’s metastatic cancer to the liver as from an “unknown primary” site. It was not until February 2006 that Dr. P.V. stated that while he initially indicated the liver cancer was from an unknown primary, subsequent review of records led him to believe that the tumor started in the prostate gland. His rationale was simply based on the fact that the Veteran had elevated PSA levels. Within the same correspondence, Dr. P.V. acknowledged that “most cancerous lesions of the liver originate in the colon.” There was no explanation as to why the elevated PSA levels would trump the fact that most cancerous lesions of the liver originate in the colon. Moreover, there has still been no explanation for this conclusion, despite the fact that the VA examiners have pointed out that elevated PSA levels are common in men the Veteran’s age (70). In subsequent correspondences (August 2006 and June 2008), Dr. P.V. continues to opine that it is more likely than not that the Veteran had prostate cancer, based solely on the elevated PSA levels. The VA opinions are far more thorough in their rationales, which are based on several findings (not just one). First, as Dr. P.V. noted, most cancerous lesions of the liver originate in the colon. Second, the examiners noted that the November 2004 ultrasound showed calcification, but no masses or abnormalities of the prostate. Third, they noted that colonic morphology tissue was found in the liver biopsy, which indicated the most likely source of the liver cancer was the colon. Fourth, the examiners pointed out that prostate cancer typically metastasizes to large bones, and there was no evidence of this in the Veteran’s case. Rather, there was probable metastasis to the scapula, which is a smaller bone. Fifth, they noted that there are multiple progress notes that state that the Veteran had positive occult blood in feces, but never hematuria. They explained that occult blood is most frequent in colonic cancer and hematuria is most frequent in prostate cancer. None of these rationales were rebutted in any way by Dr. P.V. In short, the Board finds that the VA examiners have pointed to five pieces of evidence which all suggest that the Veteran did not have prostate cancer. None of these pieces of evidence have been refuted in any way. Meanwhile, the only piece of evidence that potentially supported a conclusion of prostate cancer was elevated PSA. This piece of evidence, however, as noted by the VA examiner, was tempered by the fact that the Veteran was 70 years old, and elevated PSA is common in men of that age. The appellant submitted additional evidence of studies which she asserted supported an association between colon cancer and herbicide agent exposure. The Board remanded so that the VA examiner could comment on the articles and indicate agreement or disagreement (11/28/2017 BVA Decision; 07/31/2018 BVA Decision). In two subsequent addenda, the examiner opined that it was more likely than not that the Veteran had colon cancer, and that a search of the medical literature did not reveal a causative relationship between herbicide agent exposure and colon cancer. The primary risk factors were a diet high in fat and low in fiber; heredity; family history of sporadic colorectal cancer; inflammatory bowel disease; and a history of abdominal radiation to treat previous cancers 03/13/2018 C&P Exam). In the second addendum, the examiner noted that the studies cited and submitted by the appellant concluded that there was an increased risk of soft tissue carcinoma following exposure to phenoxy herbicides. The examiner noted that he agreed with the conclusion of the studies but noted further that they had no application to the Veteran’s case. The reason was that colon cancer is not a soft tissue carcinoma. The examiner explained that soft tissue cancers are a group of rare cancers in body tissues such as muscle, fat, blood, lymph vessels, and connective tissues and the like. Colon cancer is not a soft tissue carcinoma. Hence, it was not at least as likely as not that the Veteran’s colon cancer was causally connected to active service on any basis (09//21/2018 C&P Exam). The VA examiner not only considered the general treatises but applied all to the specific circumstances to the Veteran’s case. Sacks v. West, 11 Vet. App. 314 (1998). Again, the question is not merely whether there could be a connection, but rather whether such connection is at least as likely as not. The Board finds that the preponderance of the evidence is against such a connection. The Board notes the appellant’s and her attorney’s assertion that Dr. P. V.’s opinions should receive the greater weight because he is an oncologist, whereas the VA examiners are not specialists. The Board acknowledges that, depending on the circumstances of a particular case, there are instances where the opinion of a medical professional may garner less weight if a medical issue requires special knowledge. See Black v. Brown, 10 Vet. App. 279 (1997); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board finds that in this case, Dr. P.V.’s special training and experience in oncology does not increase the weight of his opinions. Even a specialist’s opinion must be consistent with and supported by the facts of the case on which the opinion is rendered. As discussed in detail above, the supportive medical evidence of record is against an opinion that the Veteran had prostate cancer. The weight of the medical evidence is that he had colon cancer that metastasized to his liver. For the foregoing reasons, the Board finds the opinions of the VA examiners to be more probative than that of Dr. P.V. CONTINUED ON THE NEXT PAGE (Continued on the next page)   As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for the cause of the Veteran’s death must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD W.T. Snyder