Citation Nr: 20021893 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 18-25 223 DATE: March 27, 2020 REMANDED Service connection for bladder cancer is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1962 to April 1984. He and his spouse testified before the undersigned Veterans Law Judge at a November 5, 2019 hearing. A complete transcript is of record. The record was held open for ninety days, to allow the Veteran time to submit additional evidence regarding his claim. The Veteran asserts that his bladder cancer was caused by herbicide exposure, during his service in Vietnam. The Board notes that it has been previously conceded that the Veteran was exposed to herbicides, as he was stationed in Vietnam. Service connection may be presumed for certain diseases if a Veteran was exposed to an herbicide agent during the Vietnam era, and the disease manifested to a degree of ten percent or more any time after service. 38 C.F.R. § 3.307 (a)(6), 3.309(e). However, bladder cancer is not a disease that is subject to this presumption. Id. The Veteran has pointed out that several veteran advocates had pushed to have bladder cancer added, but to date, such a designation has not occurred. That being said, service connection may still be assigned if the evidence of record is shown to make it at least as likely as not (50 percent or greater) that the bladder cancer was caused by in-service exposures. Here, the Veteran submitted two private medical opinions, which opined that the Veteran’s bladder cancer is as likely as not (50 percent or greater) due to herbicide exposure. However, the only rationale for these conclusions was that current research and medical literature suggested as much. One physician provided a research article, Exploring Exposure to Agent Orange and Increased Mortality due to Bladder Cancer, but did not explain how the research article applied to the Veteran. Specifically, this issue whether the herbicide exposure caused the condition. The other physician suggested that there are studies that provide a link between herbicide exposure and bladder cancer, but they did not identify, did not cite to, or did not submit the studies on which they based their opinion. Neither physician provided a rationale that supported their respective opinions, that explained how the Veteran’s level of exposure to herbicide agents or personal circumstances made it as least as likely as not that there was a relationship with his bladder cancer. Veterans Service Organizations have argued that bladder cancer should be added to the Agent Orange presumptive list, as contemplated by 38 C.F.R. § 3.309. However, bladder cancer is not currently considered a disease subject to the Agent Orange presumptions. The Board notes that the National Academies of Sciences, Engineering, and Medicine concluded that there was limited or suggestive evidence of an association between exposure to herbicide agents and urinary bladder cancer. See Nat’l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2018 (the 11th edition) at page 306. This was explained to mean that epidemiologic evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence. For example, a well-conducted study with strong findings in accord with less compelling results from studies of populations with similar exposures could constitute such evidence. There is limited or suggestive evidence of an association between exposure to the chemicals of interest and cancer of the urinary bladder. Although both physicians based their opinions on the current research suggesting there are studies that provide a link between bladder cancer and herbicide exposure, the National Academies of Sciences, Engineering, and Medicine were presumably aware of these studies when they issued Agent Orange Update 11, in 2018. The Board finds that the two private medical opinions of record did not provide an adequate rationale as to why the Veteran’s herbicide (or other chemical) exposure caused his bladder cancer. As such, the Board finds that a remand is necessary to obtain a VA medical opinion regarding the etiology of the Veteran’s bladder cancer. The matters are REMANDED for the following action: 1. Obtain a medical opinion to address the etiology of the Veteran’s bladder cancer. The examiner should answer the following question: (Continued on the next page)   a) Is it at least as likely as not (50 percent or greater) that the Veteran’s bladder cancer is the result of his presumed exposure to herbicide agents? Why or why not? In so doing, the examiner should review the findings of Agent Orange Update 11 (2018) which concluded that there was limited or suggestive evidence of an association between herbicide exposure and bladder cancer. (https://www.nap.edu/read/25137/chapter/1) MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fu, 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.