Citation Nr: 20046083 Decision Date: 07/09/20 Archive Date: 07/09/20 DOCKET NO. 16-11 007 DATE: July 9, 2020 REMANDED Entitlement to service connection for the Veteran’s cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1966 to May 1968, to include service in the Republic of Vietnam. The Veteran died in July 2011. The Appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (the Board) on appeal from an April 2012 rating decision. The Board previously remanded the claim in May 2019 and November 2019. Entitlement to service connection for the Veteran’s cause of death is remanded. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). As noted in the Board’s prior decisions, the Appellant seeks service connection for the Veteran’s cause of death, identified on the death certificate as pulmonary embolus and esophageal cancer. She asserts his esophageal cancer is causally related to exposure to herbicide agents during service in Vietnam. While the Veteran’s exposure to herbicide agents is conceded, esophageal cancer is not presumptively linked to this exposure. See 38 C.F.R. § 3.309(e). Service connection for esophageal cancer may be established when there is evidence of direct causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The medical evidence also demonstrates the Veteran was treated for non-Hodgkin’s lymphoma of the skin in 2005 and a tongue mass in 2006. In May 2019, the Board observed the Appellant had submitted a copy of a non-precedential May 2012 Board decision (addressing the claim of a different Veteran). This decision described medical literature supporting a link between exposure to herbicide agents and gastrointestinal cancer. The claim was remanded to obtain a medical opinion addressing whether service connection was indicated on a direct basis. See Combee, supra; see also McLendon v. Nicholson, 20 Vet. 79, 83 (2006). Following the May 2019 remand, a June 2019 medical opinion (including an addendum opinion ) was obtained. The June 2019 VA examiner noted the Veteran had a history of smoking and alcohol use which placed him in a high-risk category for gastric cancer. She opined the Veteran’s esophageal cancer was less likely than not causally linked to his exposure to herbicide agents. In November 2019, the Board determined this opinion was inadequate because the examiner’s finding of past alcohol abuse was contradicted by the medical evidence of record and the opinion did not include an explanation as to why, in light of the May 2012 Board decision, exposure to herbicide agents was not considered a risk factor for gastric cancer. An additional VA opinion was obtained in December 2019. The examiner stated, “[m]ultiple peer-reviewed studies in the medical literature have also failed to find a consistent relationship between herbicide agents and gastroesophageal adenocarcinoma.” He observed, the National Academy of Sciences had found inadequate or insufficient evidence to determine whether there is a link between herbicide exposure and esophageal cancer. The examiner stated that scientific studies established “smoking, a body mass index [BMI] higher than the lowest quartile, gastroesophageal reflux disease, and a diet that was low in fruits and vegetables accounted for almost 80 percent of cases of esophageal adenocarcinoma in the United States.” He noted the Veteran had a long history of smoking, a “usual weight” which indicated a [BMI] of 34, and was treated for a peptic ulcer in 1969. He then opined that it was more likely than not that the Veteran’s smoking history and obesity contributed to his esophageal cancer and death. Unfortunately, the December 2019 medical opinion is also inadequate. The Veteran’s smoking history is clearly reported in the medical records. However, there are only a few height and weight notations associated with the file. The do not all correspond with an elevated BMI. Accordingly, it is not clear how the examiner determined the Veteran’s “usual weight.” While the examiner stated medical literature did not show a “consistent relationship” between herbicide agents and gastric cancers, the Appellant has submitted evidence that medical studies supporting such a relationship are available (as noted in the May 2012 Board decision.) The examiner’s failure to discuss any such studies shows his review of the literature may have been incomplete. Finally, the Veteran had a history of exposure to herbicide agents and a prior diagnosis of non-Hodgkin’s lymphoma (which is presumptively linked to herbicide exposure). The examiner did not discuss the Veteran’s history of non-Hodgkin’s lymphoma and did not evaluate whether his specific medical history (herbicide agent exposure and diagnosis with a presumptive cancer) was a risk factor for developing esophageal cancer. An additional medical opinion must be obtained. See Stelf, supra. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s esophageal cancer is at least as likely as not (50 percent or greater probability) related to his active military service including his conceded exposure to herbicide agents. In providing this opinion, the examiner must address the May 2012 Board decision provided by the Appellant. In addressing this evidence, the examiner must state whether there is medical literature which suggests an association between herbicide agents and esophageal cancer. If the examiner finds that there is no such medical literature, he or she should so state. If the examiner finds this medical literature exists but it is not reliable, he or she should so state and provide an explanation for this finding. If the examiner finds this medical literature exists but it is inapplicable to the present claim, he or she should so state and provide an explanation for this finding. (Continued on the next page)   If the examiner determines the Veteran demonstrated risk factors (other than exposure to herbicide agents) for developing esophageal cancer, he or she should explain how the presence of each risk factor is established. The examiner should also address whether the Veteran’s specific medical history, including his diagnosis of non-Hodgkin’s lymphoma, is related to his development of esophageal cancer. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.