Citation Nr: 20021453 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 17-23 624 DATE: March 25, 2020 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died in September 2013. The sole cause of death was metastatic pancreatic cancer. 2. The Veteran’s fatal pancreatic cancer was not related to an event, injury or disease incurred during service, nor was it caused by a service-connected disability. 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. § 1310; 38 C.F.R. § 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from February 1969 to October 1970. He died in September 2013. The appellant is his surviving spouse. Metastatic pancreatic cancer was recorded as the sole cause of death on the Veteran’s death certificate. He was service connected for ischemic heart disease with revascularization with coronary artery bypass graft (IHD), hearing loss, tinnitus, and posttraumatic stress disorder (PTSD). The Veteran was not in receipt of a total disability rating at the time of death. As such, an award of benefits under 38 U.S.C. § 1318 is not under consideration. The appellant argues that the Veteran’s service-connected IHD caused his death. The Board previously remanded the matter in June 2019 to obtain a medical opinion to determine the following: (1) did the Veteran’s service-connected disabilities contribute to his death; and, (2) was the Veteran’s fatal pancreatic cancer related to exposure to herbicide agents in service. The Board finds there has been substantial compliance with its previous remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). In cases of service connection for the cause of death of a veteran, the first requirement of a current disability is met by the condition that caused the veteran’s death. However, the last two requirements for a service connection claim must be supported by the record: (1) an in-service incurrence or aggravation of a disease or injury, and (2) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Carbino v. Gober, 10 Vet. App. 507, 509 (1997); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disease associated with exposure to certain herbicide agents listed in 38 C.F.R. § 3.309(e) will be considered to have been incurred in service under the circumstances outlined in that section, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a)(6)(iii). Pancreatic cancer is not such a disease. However, diseases not enumerated in said regulation do not preclude service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1045 (Fed. Cir. 1994). Here, two fundamental requirements for service connection have been met. The Veteran died in September 2013 due to metastatic pancreatic cancer. Also, he served in Vietnam and exposure to herbicide agents is presumed. See DD Form 214. However, under 38 C.F.R. § 3.309(e), a medical nexus between pancreatic cancer and exposure to herbicide agents is not presumed. It follows that service connection for the Veteran’s death is warranted if: (1) any of his service-connected disabilities contributed materially to his death, or (2) his pancreatic cancer was attributable to herbicide exposure in service. While the Board acknowledges the appellant’s assertion that the Veteran’s service-connected IHD caused his death, she has not been shown competent to provide a nexus opinion in that regard. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In August 2016, a VA clinician determined there was “insufficient evidence” to conclude that the Veteran’s IHD caused or substantially contributed to his death. The reviewing clinician further reasoned that the Veteran’s other service-connected conditions, such as tinnitus and PTSD would be less likely to have caused or contributed to the Veteran’s fatal pancreatic cancer as the conditions had “no medical relationship to pancreatic cancer.” After review of the evidentiary record, a different VA clinician agreed that it less likely than not that the Veteran’s IHD contributed significantly to his death from metastatic pancreatic carcinoma. See November 2019 VA medical opinion. The reviewing clinician acknowledged the Veteran had a history of coronary bypass grafting, sick sinus and paroxysmal atrial fibrillation with a pacemaker. The record shows that during hospitalization for his pancreatic cancer, the Veteran was admitted to the intensive care unit in August 2013 for respiratory failure and then cardiac issues but that the conditions resolved prior to his death. See October 2019 medical treatment record at 58. Otherwise, records of medical treatment leading up to the Veteran’s death note the Veteran’s cardiac condition as stable. See e.g., October 2019 medical treatment record at 27, 39, 102. The November 2019 reviewing clinician noted that other than medication to control his heart rate, the Veteran’s cardiac status was stable. The reviewing clinician reiterated that metastatic pancreatic carcinoma is very aggressive, resulting in a short life expectancy. Both the August 2016 and November 2019 reviewing clinicians opined that the Veteran’s other service-connected disabilities—PTSD, hearing loss, and tinnitus—less likely than not caused or contributed to his death. In combination, the Board finds the medical opinions of the VA clinicians highly probative and affords them substantial weight. The opinions were provided by qualified medical professionals after full review of the evidence of record. As such, the Board finds the weight of the evidence is against finding a causal relationship between the Veteran’s IHD and his fatal pancreatic cancer. The weight of the evidence is also against a relationship between the Veteran’s other service-connected conditions and his fatal pancreatic cancer. Upon review of the record, a VA clinician also opined that the Veteran’s pancreatic carcinoma was less likely than not the result of exposure to herbicide agents in service. See November 2019 VA examination at 1. The reviewing clinician reasoned that evaluation of current scientific evidence by the National Academy of Science does not support a positive relationship between pancreatic carcinoma and herbicide exposure. Id. The Board finds the opinion of the reviewing clinician highly probative and affords it significant weight. The opinion was provided by a qualified medical professional after review of the claim’s file and consideration of current scientific evidence. Therefore, the Board finds the preponderance of the evidence weighs against finding that the Veteran’s fatal pancreatic cancer was attributable to herbicide exposure in service. (Continued on the next page)   In summation, the evidentiary record demonstrates that the Veteran’s service-connected disabilities did not contribute materially to his fatal metastatic pancreatic cancer and his cause of death was not attributable to herbicide exposure in service. Because the record does not show a nexus between the Veteran’s fatal pancreatic cancer and his time on active duty, service connection for the Veteran’s cause of death is denied. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Daniel Ballinger, 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.