Citation Nr: 19150976 Decision Date: 07/02/19 Archive Date: 07/01/19 DOCKET NO. 12-09 345 DATE: July 2, 2019 REMANDED The claim of entitlement to service connection for chronic myeloid leukemia (CML) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1966 to October 1969, with service in the Republic of Vietnam from July 1967 to July 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2015, the Veteran and his spouse testified before the undersigned Veterans Law Judge at a videoconference. Thereafter, the Board remanded this claim in September 2015. Entitlement to service connection for chronic myeloid leukemia The Board finds that remand is appropriate to obtain an adequate medical opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran has pursued this claim for several years, and multiple conflicting etiological opinions are of record. In January 2003, the Veteran’s private Oncologist/Hematologist, Dr. MM, submitted two statements. In the first statement, Dr. MM requested that consideration was given to the scientific merit of the possibility that the Veteran’s malignancy may be secondary to herbicide exposure during his Vietnam service. The physician also noted that the Veteran had exposure to benzene through diesel and gasoline exhaust which had been linked to leukemia. In a subsequent letter, Dr. MM noted taking a detailed medical history and conducting tests and opined it was at least as likely as not that the exposure to herbicides and benzene (diesel and gasoline fumes) in Vietnam was the cause of the Veteran’s leukemia. The Veteran was afforded a VA examination in June 2003. The VA examiner opined that based on the best available evidence regarding exposure to benzene or other chemicals and the risk of developing CML, a one year exposure to benzene in Vietnam could not be conclusively shown to be as likely as not caused by his exposure to benzene and diesel fuel from exposure during Active Duty. In June 2003, Dr. MM submitted another opinion. The private physician again requested special consideration to be given to the scientific merit of the possibility that the Veteran’s malignancy may be possibly related to the herbicide exposure during his tour duty in Vietnam and occupational exposure to benzene through diesel and gasoline exhaust which had been linked to leukemia. In April 2005, a VA addendum opinion was obtained. The VA examiner opined that it was not at least as likely as not that the Veteran’s CML was related to his in-service exposure to herbicides or benzene. In May 2006, Dr. MM stated that the Veteran’s CML may in some form be related to his benzene, petroleum distillate, and Agent Orange exposure and that there may actually be a high probability that the chemicals contributed to the CML. In October 2006, Dr. MM stated that there was a high likelihood that the Veteran’s chemical exposure may have well contributed to his CML and with known toxicity latency periods producing gene mutations and chromosomal aberrations, special consideration should be given to the Veteran’s claim. In September 2007, Dr. AK, another private Oncologist/Hematologist, submitted an opinion. Dr. AK opined that the Veteran’s exposures may have contributed to the development of the Veteran’s CML and to the relative difficulty of controlling the disease. In February 2010, Dr. MM provided another opinion. He opined that CML should fall into the category of b-cell leukemia and lymphomas that are on the list of presumptive diseases associated with Agent Orange exposure. He noted that evidence suggests a stem cell nature, and because b-cells are involved, CML should be included. Dr. MM explained that lymphomas and leukemias are all bone marrow malignancies and that leukemias and lymphomas both have chromosomal damage, and as such, they are related cancers because they involve the uncontrolled growth of cells similar in function and origin. He explained that abnormal cells accumulate, interfering with the production of normal blood cells and/or platelets, and that if a positive causal effect from chemical exposure to the diseases already on the list are acknowledged, then CML must be included. Specifically addressing CML, the physician explained that it is a cancer that is not inherited, but rather caused by an outside mutagenic source. In the case of the Veteran, the mutagenic source includes Agent Orange, which is known to cause chromosomal aberrations, Agent Blue, and Agent White. The physician also noted that the Veteran was exposed to diesel exhaust. The physician stated that according to the National Cancer Institute and Leukemia Lymphoma Society as well as other medical and scientific organizations, benzene exposure has been linked to leukemia. He explained that his belief was the compilation of these chemical exposures led to the development of CML in the Veteran. Once the bone marrow is damaged, there can be latency periods of up to 40 years before the disease appears. It is therefore his opinion that there is strong evidence that the chemical exposures are the cause of the Veteran’s CML. In February 2010, Dr. AK noted the Veteran’s multiple exposures during his service in Vietnam, to include Agents Orange, White, and Blue, which included dioxins, arsenic, picloram, and other carcinogens, benzene, arsenic, and other carcinogens contained in diesel fuel and exhaust. The physician opined that CML is of stem cell origin like other b-cell leukemias and likely associated with Agent Orange exposure. The physician noted that multiple myeloma, Hodgkin’s disease, CLL, hairy cell leukemia and lymphoma are also conditions that have developed in other Veterans as a result of their exposure to Agent Orange. Dr. AK explained that these diseases are bone marrow related diseases. Once the bone marrow is damaged by chemical exposure, the latency period for disease to materialize could be 10 years or more. Therefore, Dr. AK opined that the Veteran’s exposures contributed to the development of his CML. He further opined that the claim for compensation for CML was likely as being associated with the abovementioned exposures, all being carcinogens, and should be granted. In March 2011, a VA expert medical opinion was obtained to determine whether CML was classified as a type of b-cell leukemia. The examiner provided an explanation as to the development process of CML and noted that CML was thought to occur because of a transformation of a hematopoietic stem cell because of the presence of the Philadelphia chromosome. The examiner explained that in b-cell leukemia, only the cells of b-cell lineage are involved. The insult with CML occurs in the stem cell and that the B-cells may or may not be involved, although this is not the primary process. As such, the expert opined that she would not classify CML as a type of b-cell leukemia. The examiner opined that Veteran’s CML was not caused by or a result of his exposure to Agent Orange. The examiner stated that there was no known association for chemical exposure specifically related to the development of CML According to the examiner, the only known risk factor for the development of CML was exposure to high dose radiation. A March 2016 VA opinion was provided. The VA examiner, a physician, noted that the Veteran had Philadelphia positive CML which was not b-cell leukemia. The VA examiner cited to a medical article that CML is related to the Philadelphia genetic risk factor with a finding of increased radiation exposure as its known risk factor. In April 2016, an addendum opinion was obtained. The VA examiner, a Certified Physician’s Assistant, opined that CML was not a b-cell leukemia. The VA examiner explained that CML and b-cell leukemia are two broad, mutually exclusive classifications of leukemias. He further explained that their etiologies are different as are their treatment modalities. The VA examiner noted that the only accepted risk factors for CLM according to the American Cancer Society are radiation exposure, being exposed to high-dose radiation such as being a survivor of an atomic bomb blast or nuclear reactor accident increases the risk of getting CML. Additionally, the risk of getting CML increases with age and that there are no proven risk factors for CML. The examiner explained that the risk of getting CML did not seem to be affected by smoking, diet, exposure to chemicals, or infections. Regarding the opinions on record, the VA examiner stated that any opinions by the Veteran’s physicians and those of the internet articles are their own and he would have no further comment other than what he has already commented. The Board finds that the 2016 VA opinions are not adequately responsive to the various opinions of record. The examiner did not provide any discussion as to why the conclusions reached are correct and the prior favorable opinions are not. This is particularly significant, as the favorable opinions come from experts in the fields of hematology and oncology. Accordingly, the Board will remand the claim for another opinion to reconcile the conflicting evidence of record. The matter is REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the Veteran’s chronic myeloid leukemia from a VA examiner who, if possible, specializes in the fields of hematology and oncology. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s CML can be characterized as a b-cell leukemia or is analogous to a b-cell leukemia. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s CML had onset in, or is otherwise related to, active service to include exposure to Agent Orange and/or benzene. (c.) In reaching these conclusions, please address the following: 1) the opinions of record by Dr. MM and Dr. AK prior to 2010; 2) the June 2003 VA opinion; 3) the April 2005 VA addendum opinion; 4) the February 2010 opinions by Dr. MM and Dr. AK; 5) the March 2011 VA expert opinion; 6) the March 2016 VA opinion; 7) the April 2016 VA addendum opinion; and 8) the articles submitted by the Veteran regarding the correlation between CML and exposure to Agent Orange and/or benzene. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.