Citation Nr: 19119331 Decision Date: 03/15/19 Archive Date: 03/15/19 DOCKET NO. 15-24 114 DATE: March 15, 2019 ORDER Entitlement to service connection for gastrointestinal stromal tumor, to include as secondary to service-connected kidney cancer, is denied. Entitlement to service connection for carcinoid neuroendocrine tumor claimed as duodenum carcinoid and neuroendocrine cancer (neuroendocrine tumors), to include as secondary to service-connected kidney cancer, is denied. FINDINGS OF FACT 1. The Veteran served at U.S. Marine Corps Base Camp Lejeune, North Carolina (Camp Lejeune) from April 1962 to October 1963; thus, the Veteran was exposed to contaminated water during his active military service. 2. The Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors are not caused or aggravated by service-connected kidney cancer and are not otherwise related to an in-service injury or disease, to include contaminated water at Camp Lejeune. CONCLUSIONS OF LAW 1. The criteria for service connection for gastrointestinal stromal tumor are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(f), 3.310. 2. The criteria for service connection for neuroendocrine tumors are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(f), 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Marine Corps from January 1962 to May 1966. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in August 2018 when it was remanded for further development. Service Connection 1. Gastrointestinal Stromal Tumor 2. Neuroendocrine Tumors The Veteran and his representative contend that the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors were caused by exposure to contaminated drinking water at Camp Lejeune. Alternatively, the theory that the Veteran’s cancers were caused or aggravated by the Veteran’s service-connected kidney cancer has been raised by the record and will be addressed below. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted 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. Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). During the pendency of this appeal, effective March 14, 2017, VA amended its adjudication regulations relating to presumptive service connection, adding eight diseases that are associated with contaminants present in the water supply at Camp Lejeune. 82 Fed. Reg. 4184-85 (Jan. 13, 2017) (codified at 38 C.F.R. §§ 3.307, 3.309). To establish presumptive service connection for a disease associated with exposure to contaminated water at Camp Lejeune, a Veteran must show the following: (1) that the Veteran served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that the Veteran suffered from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). The Veteran’s military personnel records demonstrate that the Veteran was stationed at Camp Lejeune on active duty from April 1962 to October 1963. However, the Veteran’s cancers, diagnosed as gastrointestinal stromal tumor and neuroendocrine tumors, are not included in the list of diseases associated with exposure to contaminants in the water supply at Camp Lejeune under 38 C.F.R. § 3.309(f). Therefore, presumptive service connection for these two cancers is not available based on exposure to contaminants in the water supply at Camp Lejeune under 38 C.F.R. § 3.309(f). However, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can otherwise be established. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). In other words, the fact that a veteran may not meet the requirements for service connection on a presumptive basis does not in and of itself preclude the establishment of service connection, as entitlement may alternatively be established on a direct basis. The questions for the Board are whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease; or whether the Veteran has a current disability that is proximately due to or the result of or is aggravated beyond its natural progress by his service-connected kidney disease. Regarding the theory of direct service connection, the Board concludes that, while the Veteran has current diagnoses of gastrointestinal stromal tumor and neuroendocrine tumors, and evidence shows that he was exposed to contaminants in the water supply at Camp Lejeune, the preponderance of the evidence weighs against finding that the Veteran’s diagnoses of gastrointestinal stromal tumor and neuroendocrine tumors began during service or are otherwise related to an in-service injury, event, or disease. The record contains conflicting medical opinions regarding whether the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors are at least as likely as not related to an in-service injury, event, or disease, including exposure to contaminated water at Camp Lejeune. VA medical experts in March 2014, January 2015, and November 2018 opined that the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors were less likely than not incurred in or caused by his military service, including exposure to contaminated water at Camp Lejeune. In support of her opinion, the March 2014 VA medical expert noted the Veteran’s exposure to contaminated water at Camp Lejeune, and she noted the Veteran’s occupational exposures to organic solvents and other chemicals during his employment post-service. The VA medical expert stated the Veteran’s lifetime occupational exposures to organic solvents and other chemicals found in the automotive industry would have far exceeded his seven-month exposure to water contaminants at Camp Lejeune. Further, the VA medical expert stated that aside from hereditary risk factors, the etiologies of gastrointestinal stromal tumors and neuroendocrine tumors are unknown. The Board acknowledges that the Veteran’s service personnel records reflect the Veteran was stationed at Camp Lejeune on active duty from the beginning of April 1962 to October 1963. Thus, the Veteran’s exposure to water contaminants was greater than the seven months the VA medical expert stated. The January 2015 VA medical expert reasoned that the medical literature does not support that gastrointestinal stromal tumors and neuroendocrine tumors are caused by the water contaminants at Camp Lejeune. Further, the medical expert stated that the etiology of these tumors is unknown, apart from hereditary risk factors. In support of her opinion, the November 2018 VA medical expert addressed the specific solvents in the water at Camp Lejeune, and that the medical literature does not support that they cause gastrointestinal stromal tumors and neuroendocrine tumors. In addition, the VA medical expert stated that the medical literature shows that occupational studies of exposure to the same chemicals found at Camp Lejeune, but to include exposure for many years, illustrates that such long-term exposure does not show a causal relationship between exposure to the chemicals and the development of gastrointestinal stromal tumors and neuroendocrine tumors. The physician also discussed that the Veteran had several risk factors of age and gender for the gastrointestinal stromal tumors. She also noted that the Veteran had a family history of gastric tumors and gastric cancer, indicating there may have been significant genetic risk factors for the Veteran’s tumor, although she noted that the majority of patients with gastrointestinal stromal tumors do not have a family history of such tumors. She also explained that the Veteran had a risk factor for carcinoid tumors of tobacco smoking, along with the family history of tumors in the stomach that suggested a genetic predisposition, although specific cell types were not available. The evidence in favor of the Veteran’s claims include two private opinions. In September 2018, Dr. J.A., a private physician, opined that the Veteran’s rare gastrointestinal tumor is directly related to the contaminated water at Camp Lejeune. Dr. J.A. provided no rationale in support of his opinion. In October 2018, Dr. M.B., a private physician, opined that without “knowing what contaminants were in the water to which he was exposed, I can only speculate, but his cancers may have been related to service exposures during his time in the Marines.” In support of his opinion, Dr. M.B. stated that with the multitude of malignant conditions the Veteran has had, it raises the question as to whether these malignancies may be related to prior exposures. Further, Dr. M.B. noted that the Veteran was likely exposed to a number of potential carcinogens during his service. The Board places more weight of probative value on the VA medical opinions than on the September 2018 and October 2018 private medical opinions. In particular, the Board places the most weight of probative value on the November 2018 VA medical opinion as the opinion includes a detailed discussion of the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors, including the Veteran’s specific risk factors for such tumors, and the rationale includes a thorough review of the medical literature that illustrates the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors are not related to the contaminated water at Camp Lejeune. In contrast, the September 2018 private physician provided no rationale in support of his opinion. The October 2018 private physician opined that the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors “may have been” related to the Veteran’s in-service exposures. In addition, the October 2018 private physician stated he could only “speculate” as to his opinion. Thus, the Board concludes that the October 2018 private opinion is speculative and little weight of probative value is warranted for the opinion. The Board acknowledges that the March 2014 VA medical expert stated that the Veteran’s exposure to water contaminants lasted seven months, which is much less than his actual exposure while stationed at Camp Lejeune as he was stationed there from early April 1962 to October 1963. However, the November 2018 VA medical opinion includes detailed rationale that is supported by the record. Therefore, the most weight of probative value is afforded to the November 2018 VA opinion. While the Veteran generally believes his gastrointestinal stromal tumor and neuroendocrine tumors are related to contaminated water at Camp Lejeune, he is not competent to provide a nexus opinion in this case. This issue is medically complex as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the November 2018 VA medical opinion. As such, service connection on a direct basis for the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors is denied. Service connection may also be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. An August 2018 Board decision granted service connection for kidney cancer, and a September 2018 rating decision implemented the award of service connection. In addition, as is noted above, the Veteran has current diagnoses of gastrointestinal stromal tumor and neuroendocrine tumors. Therefore, the first two elements required for secondary service connection are met. The question for the Board is whether the Veteran’s gastrointestinal stromal tumor and/or neuroendocrine tumors are proximately due to or the result of or were aggravated beyond their natural progress by his service-connected kidney cancer. As to this question, the November 2018 VA medical expert opined that it is less likely than not that the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors were caused or aggravated by the Veteran’s kidney cancer. In support of the opinion, the VA medical expert stated that the Veteran’s tumors are distinct tumors with different cell types, and that the medical literature illustrates that kidney cancer is not considered a cause or a risk factor for either gastrointestinal stromal tumor or neuroendocrine tumors. Further, the VA medical expert stated that the Veteran’s manifestations of his gastrointestinal stromal tumor and neuroendocrine tumors are consistent with the natural history of gastrointestinal stromal tumor and neuroendocrine tumors with no evidence of aggravation or increased severity due to kidney cancer. In addition, she stated there is no evidence that the treatment or management of his gastrointestinal stromal tumor and neuroendocrine tumors was affected or limited by his kidney cancer. The Board gives great probative weight to the opinion of the November 2018 VA medical expert as the opinion contains a detailed discussion of the Veteran’s medical history and contains references to medical literature to support the conclusions. As such, service connection for the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors on a secondary basis is denied. In summary, the preponderance of the evidence is against a finding that the Veteran’s gastrointestinal stromal tumor and neuroendocrine tumors are related to the Veteran’s service, including as due to exposure to contaminated water at Camp Lejeune, or are secondary to his service-connected kidney cancer. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App., 49, 53-56 (1990). M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel