Citation Nr: 21000234 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 14-27 899 DATE: January 4, 2021 ORDER Entitlement to service connection for lymphoma, to include non-Hodgkin’s lymphoma, to include as secondary to ionizing radiation exposure, is denied. FINDING OF FACT The objective evidence of record shows the Veteran did not participate in “radiation-risk activity,” as defined by VA regulations, there is no evidence otherwise of exposure and the conceded and assigned level of exposure to ionizing radiation for the purposes of the advisory opinion required from the VA Undersecretary for Health under the relevant regulation is no greater than 1.25 rem; lymphoma as variously diagnosed is not proximately due to or the result of a service-connected disease, nor did it manifest to a compensable degree within one year of separation from active service. CONCLUSION OF LAW The criteria for service connection lymphoma to include non-Hodgkin’s lymphoma, to include as secondary to ionizing radiation exposure, have not been met, nor are they presumed to be. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310, 3.311 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Air Force from January 1954 to October 1957. In November 2014, the Board remanded the appeal for evidentiary development. It has since been returned to the Board for further consideration. Service Connection Generally, service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) The existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing and in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was “noted” during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). Exposure to Radiation Service connection for a disability attributable to exposure to ionizing radiation during service will be presumptively granted. 38 C.F.R. § 3.309(d). Service connection can be demonstrated by three methods: (1) Under 38 C.F.R. § 3.309(d), if the veteran is radiation-exposed and diagnosed with one of the 15 types of cancer, including brain cancer, which are presumptively service connected; (2) under 38 C.F.R. § 3.311(b), if the veteran is diagnosed with a radiogenic disease and certain conditions are met; or (3) by establishing the elements for direct service connection. See Davis v. Brown, 10 Vet. App. 209, 211 (1997). A radiation-exposed veteran is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. Radiation-risk activity is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. Radiation-risk activity also includes certain service on the grounds of gaseous diffusion plants located in Paducah, Kentucky, Portsmouth, Ohio, and Oak Ridge, Tennessee; in certain circumstances, service before January 1, 1974, on Amchitka Island, Alaska if, during such service, the veteran was exposed to ionizing radiation in the performance of duty related to the Long Shot, Milrow, or Cannikin underground nuclear tests; or service in a capacity which, if performed as an employee of the Department of Energy, would qualify the individual for inclusion as a member of the Special Exposure Cohort under section 3621(14) of the Energy Employees Occupational Illness Compensation Program Act of 2000. See 38 C.F.R. § 3.309(d)(3)(ii). Second, radiogenic diseases will be service connected provided certain processing conditions are met. 38 C.F.R. §§ 3.303(d), 3.311. Pursuant to 38 C.F.R. § 3.311, when it is determined that: (1) The Veteran was exposed to ionizing radiation in service; (2) he subsequently developed a radiogenic disease; and (3) such disease first became manifest within a period specified by the regulations, a request for available records concerning the veteran’s exposure to radiation will be made and the case will be referred to the Under Secretary for Health for review as to whether sound scientific medical evidence supports the conclusion that it is at least as likely as not that the veteran’s disease resulted from radiation exposure during service. 38 U.S.C. § 501 (2012); 38 C.F.R. § 3.311(b). The term radiogenic disease means a disease that may be induced by ionizing radiation. 38 C.F.R. §§ 3.311(b). The diseases listed in 38 C.F.R. § 3.309(d) are diseases in which the VA has determined that a positive association with radiation exposure exists. For cancer, the disease must have manifested five years or more after exposure. 38 C.F.R. § 3.311(b)(5). This section does not provide presumptive service connection for radiogenic diseases, but only outlines a procedure to be followed for adjudication purposes. Medical opinions are ultimately the criteria upon which service connection rests under this regulation. Entitlement to service connection for lymphoma, to include non-Hodgkin’s lymphoma, to include as secondary to ionizing radiation exposure. The service treatment records (STRs) show a September 1955 in-service treatment note, in which the treatment provider assessed the Veteran with heat rash in his right armpit. The note mentioned the bursa sacks, but noted no further information. A treatment note in October 1956 appears to state a finding of a swollen, tender node in the left groin. In both an April 1955 flying class III examination and the September 1957 separation examination, the categories of “head, face, neck, and scalp” and “skin, lymphatics” were found to be normal. The post-service record shows a June 1958 treatment note, in which the treatment provider found psoriasis of both legs, with the Veteran complaining of swelling and pain in the knees. Additionally, he found thickened , sharply defined right-leg lesions of 3 weeks duration. In November 1958, the Veteran was hospitalized at a VA facility with a great number of psoriatic lesions on his lower extremities, elbows and on other parts of his body. The Veteran reported having these lesions for at least the past 3 years, they gradually became larger, they have appeared in more places, and they itch. He further complained of bilateral-knee pain as a continuous ache. On examination, the treatment provider found large, half-dollar-sized, clearly circumscribed, scaly lesions on a “red, elevated base,” appearing on the lower legs and elbows. He further found a large solitary lesion on the right side of the abdomen, giving the treatment provider the initial impression of psoriasis. A VA dermatologist that day found the lesions were typical psoriasis of the chronic type. The Veteran reported one year’s duration, beginning while stationed in Japan, and he has “weakness” of the legs preventing him from working. He was prescribed 5 percent crude coal-tar ointment and showed improvement when discharged. In November 1998, the Veteran was diagnosed at VA with malignant lymphoma, nodular, large cell, stage 4 with bone-marrow involvement, and he underwent chemotherapy. By January 1999, the Veteran had completed his third cycle of chemotherapy. In October 1999, the Veteran underwent a stem cell transplant at VA for lymphoma. Yearly analyses at VA from 1999 through 2003 of biopsy specimens initially showed results consistent with the Veteran’s history and diagnosis of follicular large B-cell lymphoma, with no results indicating non-Hodgkin’s lymphoma. However, the October 2001 report noted that, in light of the aggregates of small lymphocytes, low grade non-Hodgkin’s lymphoma could not be excluded. The Veteran underwent a bone-marrow transplant in March 2002. In September 2002, the Veteran reported doing well, he was working daily on his farm, he denied any hospital admissions, but his hyperglycemia has been uncontrolled. Restaging (imaging) over the course of 7 years showed by May through September 2005 remission and no clinical evidence of progression, as the Veteran “from lymphoma point of view seems to be free.” In the period of 2006 through 2010, the Veteran was followed and monitored with scans at VA for recurrent lymphoma. A hematology and oncology note in November 2007 noted the Veteran has had no recurrence of lymphoma. A February 2008 assessment stated no evidence of disease and, by March 2008, lymphoma was noted as stable. Although the Veteran’s problem was stated in March 2011 as stage 4 with bone-marrow involvement, he was assessed at that date as “clinically free of disease.” Although having a stem cell transplant in October 1999, neck biopsies at VA in October 2011 gave clinical indication of a new non-Hodgkin’s lymphoma and follicular center cell low-grade lymphoma. A December 2011 VA hematology and oncology note states the Veteran had a lymph node removed from the posterior neck which was low-grade lymphoma, a positron emission tomography (PET) scan had been done which showed no evidence of disease and his neck had some minor activity in a couple of lymph nodes, which was thought to be on the left side of the lesion that was removed. An August 2012 VA interventional radiation therapy note states the Veteran has B-cell non-Hodgkin’s lymphoma is most consistent with follicular lymphoma, with multiple lymph nodes now bilaterally in the neck and the groin. The Veteran reported the neck nodes hurt him when he turns his neck and he feels them pressing somewhat on his airway, inducing coughing. The Veteran’s assessment stated follicular lymphoma, with enlarged lymph nodes. His treatment provider was considering treatment by a radiation oncologist for radiation therapy at these sites to reduce symptoms. VA treatment notes between August and October 2014 noted in the Veteran’s assessment for other disorders that there was no evidence of recurrent lymphoma on clinical examination. Throughout the first half of 2015, monitoring and examination detected the progression of the Veteran’s lymphoma. A June 2015 medical statement by the Veteran’s VA treatment provider states the Veteran has terminal stage 4 lymphoma, with spinal metastases. That month, the Veteran was assessed with lymphoma in the spine. His treatment provider noted the Veteran had undergone palliative radiation therapy to his ribs, as well as his spine, with the subsequent bone scan and MRI demonstrating bony progression of his lymphomatous metastases. The bone scan specifically showed metastatic bone disease with multiple lesions involving T3, T9, L3, and fusiform rib lesions involving the left 2nd rib and right 5th rib. In February 2016, the Veteran presented at VA with complaints of difficulty in ambulating. The hematology and oncology note stated the Veteran’s history of follicular lymphoma, “status post several lines of chemotherapy.” After physical examination, the treatment provider assessed the Veteran with follicular lymphoma, but “no evidence of disease clinically.” A CT scan that day revealed “no clinical evidence of spinal cord compression.” In the period of March 2017 to July 2020, the Veteran continued to be followed at VA for lymphoma, carrying diagnoses variously of malignant lymphoma, follicular lymphoma and non-Hodgkin’s lymphoma. A VA treatment provider in February 2018 observed that the Veteran was possibly recurrent. In January 2020, the Veteran was noted as currently receiving chemotherapy. The Veteran contends he was exposed to radiation in service when he took leave to visit the ground zero site at Hiroshima, Japan in 1954. One of his statements specifies only Nagasaki as the destination for his visit, while still another statement refers to both cities as being visited by him. The Veteran further contends he developed skin lesions after his October 1957 separation from active service and he sought treatment in 1958 at Amarillo VA Medical Center. VA treatment records confirm the Veteran was diagnosed with lymphoma in 1998. He asserts his doctor told him the radiation exposure at the Hiroshima and Nagasaki sites was enough to cause his current diagnosis of cancer and the passage of time before its manifestation is consistent with the development of the disease. The Veteran has therefore implicitly concluded that, as he visited a radiation site during active service, developed skin lesions soon after separation as an initial sign of cancer, then later developed cancer in the form of lymphoma, the disease should be service connected under the relevant regulation. At the outset, the Board notes the Veteran was not a member of the United States Occupational Force in Japan in the period of September 1945 to July 1946, nor is he contending that he served in this capacity. Additionally, the October 2015 response by the Defense Threat Reduction Agency (DTRA), an agency of the United States Department of Defense, to initial inquiries from the Agency of Original Jurisdiction (AOJ) states, in examining the Veteran’s remaining service records in existence, to include his Report of Transfer or Discharge and unit morning reports of his units from 1954 to 1957 to verify his possible presence at the Pacific Proving Ground (PPG) and the Nevada Test Site (NTS), the DTRA’s Nuclear Technologies Department constructed a table based on the above information, whereby the Veteran’s assignments and postings during active service could be matched with the various nuclear test periods. The department’s memorandum concluded that historical records do not document the Veteran’s presence with either the American occupation forces in Hiroshima or Nagasaki or his participation in United States atmospheric nuclear testing, as defined by VA. Therefore, any “radiation-risk activity,” as defined by VA under 38 C.F.R. § 3.309 (d)(3), could not be established. Consequently, as already stated above, the Veteran’s sole contention is exposure to ionizing radiation during active service while simply visiting at least one of the sites of atomic detonation in Japan. When the Board remanded the claim in November 2014, its concern was that a review of the record revealed that a dose assessment for the Veteran’s claimed exposure had not been obtained, if in fact it could be determined. Therefore, the Board found that additional development in the form of a dose estimate was required, consistent with 38 C.F.R. § 3.311(a)(2)(m). The Board noted that the record showed no official evidence of exposure and indeed the Board again notes at present that the DTRA October 2015 memorandum approximately a year later states “after a search of available dosimetry data, we found no record of radiation exposure for [the Veteran].” Nonetheless, the Board concluded in its November 2014 Remand that, in view of the skin problems and lab findings shortly after service, the claimed exposure and the current diagnosis, additional development was required to ascertain what radiation exposure level might have been experienced. However, the initial response by DTRA’s Nuclear Technologies Department had not furnished a dose estimate, as originally requested by the AOJ. In November 2015, the AOJ contacted the Department of the Air Force’s Air Force Medical Support Agency (Radiation Health) to request a dose estimate and instructed that office that, for the purposes of providing this estimate, it should be assumed the Veteran’s contentions of visiting Hiroshima and/or Nagasaki for three days during service (1954-1956) are true and added a copy of the Board’s Remand, which directed, “If a specific estimate cannot be made, a range of possible doses should be provided.” The February 2016 response stated the occupational radiation exposure monitoring records in the United States Air Force Master Radiation Exposure Registry (MRER) showed no external or internal radiation-exposure data for the Veteran, adding that the MRER is not the single repository for occupational radiation exposure monitoring for all Air Force personnel. The response acknowledged that, although the records date back to 1947, there have been cases in which early records were maintained in an individual’s military medical record or by the local unit and were never forwarded for inclusion in MRER. Nonetheless, the response concurred with DTRA’s memorandum and added that the Air Force “would not have monitored personnel in a leave of absence status who visited a site of their own volition…. [VA] retains the authority to determine whether or not an individual veteran’s specific health condition may be attributed to military service. The US Air Force has no dose information for this veteran.” In April 2020, VA rendered an administrative decision after its Administrative Review of Entitlement to Service Connection for Non-Hodgkin’s Lymphoma under provisions of 38 C.F.R. § 3.311, which summarized the procedural history of the Veteran’s claim, as well as the series of inquiries by the AOJ and the responses, and recommended “to uphold the previous determination of denial of service-connection for Non-Hodgkin’s Lymphoma as the evidence shows the Veteran was not exposed to radiation during his responsibilities while performing active duty service.” In May 2020, the VA Director of the Compensation Service in turn provided her own summary of the record and of the Board’s November 2014 Remand to VA’s Undersecretary for Health, requesting that he provide a dose estimate, to the extent feasible, and an opinion whether it is likely, unlikely or as likely as not that the Veteran’s non-Hodgkin’s lymphoma resulted from exposure to radiation in service, further requesting that the Undersecretary set forth clearly the rationale for his opinion. The June 2020 response from the Director of the Post-9/11 Environmental Health Program, in the office of the Undersecretary for Health, at the outset states radiation dose is the prime factor to consider when determining causation of radiation-induced disease. He added that where presumption does not exist, being near a radiation source does not necessarily mean a significant exposure occurred and the dose must be determined through direct measurement or reconstruction methodology. In the Veteran’s case, the analysis applied the highest radiation dose reported by DTRA for veterans who were part of the occupation forces of Japan in 1945 and 1946. DTRA’s March 2020 fact sheet for its relevant report states, “Doses received by veterans at Nagasaki were generally low; the approximate maximum external dose based on a presence for [the] entire interval from September 16, 1945, to July 1, 1946, is 1.25 rem [the ‘Roentgen equivalent man’ measure of dosage]. Potential exposure to occupation troops assigned to Hiroshima was markedly lower due to radioactive decay prior to the delayed October 6, 1945[] entry into the city.” The Director added that doses for veterans would actually be less than 1.25 rem, due to the radioactive decay of fission products and the overall dose would be near background levels after nearly 9 years of decay. “For the purposes of this advisory medical opinion, we will concede and assign the dose as 1.25 rem.” However, based on research of the average annual equivalent dose from natural background radiation in the United States and the health effects from high-dose exposures, below levels of 10 rem above background from all sources combined, “the observed radiation effects in people are not statistically different from zero.” As the Veteran’s assigned total ionizing radiation dose is 1.25 rem, “it is unlikely that Non-Hodgkin’s lymphoma was caused by exposure to ionizing radiation while in military service (emphasis in original).” From the foregoing, the Director of Compensation Service rendered an advisory opinion in June 2020, in which, after summarizing the record and the above response, noted the laboratory findings reported in the 1958 hospitalization are noted, but concluded that an etiological relationship to current findings (some 40 years later) is not likely, essentially undiagnosed lymphoma for 40 years is highly unlikely and, while it is known that diseases can have a latent onset due to radiation exposure, the levels of exposure are not likely to have caused such disease regardless of the length of the latent period. She further concluded that, based on the scientific evidence referenced in the memorandum from the VA Undersecretary for Health and the review of the evidence in its entirety, “it is our opinion that there is no reasonable possibility that non-Hodgkin’s lymphoma is the result of ionizing radiation exposure during military service.” To begin with the most significant finding in the record, the Veteran, consistent with the regulation, was assigned the highest dose possible for service members in the period of the Veteran’s active service as it relates to the atomic detonation sites of Hiroshima and Nagasaki, based on 9 years of fission decay. See 38 C.F.R. § 3.311(a). That assigned dose level, based on the clinical research data cited in the memorandum from the Undersecretary’s office, falls far below the discernible effects of radiation-induced disease from high exposure, in fact being “not statistically different from zero.” The advisory opinion in which this information is set forth is a “credible source” under the regulation, as it was prepared by persons certified in health physics and, as discussed below, is based on an analysis of the facts and circumstances of this claim, as discussed above at length. 38 C.F.R. § 3.311(a)(3)(ii). The Board will note here that it finds the June 2020 memorandum from the Director of the Post-9/11 Environmental Health Program, in the office of the Undersecretary for Health, to constitute sound scientific evidence. First, the Director, in using the highest radiation dose reported by DTRA, looked to that agency’s March 2020 fact sheet, under the title of “ NTPR [Nuclear Test Personnel Review]: Hiroshima and Nagasaki Occupation Forces,” dated March 2020, which is constantly revised as radiation level estimates for atomic detonations in Japan are updated based on further research. For the general comparisons made to overall radiation exposure levels of all Americans on an annual basis, the Director further consulted the position statement (PS010-3) of the Health Physics Society, “Radiation Risk in Perspective,” revised in May of 2016. This material was evaluated by the Director’s analyst and the results reviewed by the Director himself, both of whose qualifications are discussed in detail below. The Board itself does not have the expertise to arrive at a dose estimate, but the foregoing expert analysis provides sufficient reasons for the Board to find the above determinations to be sound. Although the Veteran’s service records cannot confirm exposure, as he was on leave at the time of the claimed exposure and, as stated in the February 2016 DTRA Nuclear Technologies Department memorandum, the Air Force therefore would not have monitored or known of possible exposure However, even if exposure is conceded as a finding of fact, the highest dose assignment, as discussed above, simply is not high enough for the Veteran to have incurred a radiation-induced disease, such as lymphoma, whether follicular large B-cell or non-Hodgkin’s lymphoma. Additionally, although the Veteran was examined and assessed with psoriatic lesions in June 1958 and later hospitalized and treated for that disorder in November 1958, nothing further in the medical evidence of record in the form of a further diagnosis indicates a causal connection with radiation exposure, nor does the record offer evidence of post-service radiation exposure. Moreover, the Board will note here that the record shows, as reported by the Veteran, a family history of his mother’s stomach cancer and his brother’s skin cancer (melanoma), suggesting as a factual determination the Veteran’s genetic pre-disposition to cancers of various kinds. Lastly, as stated above, certain chronic diseases are eligible for presumptive service connection. Chronic diseases under 38 C.F.R. § 3.309(a) include “tumors, malignant” and the record shows diagnoses for malignant lymphoma, a form of cancer. However, the record offers no evidence of the manifestation of the above disorder diagnosed as such or characterized as any other form of lymphoma to a compensable degree within one year of separation from active service. Additionally, because it was never identified in service or directly after, and putting aside the lack of medical evidence of treatment for those disorders at that time, it would be otherwise impossible to establish continuity of symptomatology based on the identification of symptoms during, directly after or continuing for a longer period after active service. Consequently, the presumption of service connection for lymphoma as a chronic disease is not available to the Veteran. Turning to the Veteran’s lay evidence, the Board has carefully reviewed and considered the Veteran’s Statements in Support of Claim from August 2011 through June 2015, to include the statement accompanying the Veteran’s May 2013 Notice of Disagreement, as well as his numerous reports to treatment providers, as they appear throughout the record. The Board acknowledges that lay persons are competent to report symptoms which impact their senses, events they observe and the drawing of certain inferences and there is no reason otherwise to doubt their credibility. However, although it is error to reject categorically a lay person as competent to provide a nexus opinion, not all questions of nexus are subject to non-expert opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Whether a lay person is competent to provide a nexus opinion depends on the facts of the particular case. In Davidson, the United States Court of Appeals for the Federal Circuit (Federal Circuit) drew from an earlier decision to explain its holding. In that earlier decision, the Federal Circuit stated the following: “Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Federal Circuit provided an example, stating that a lay person would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question, such as a form of cancer. Id. at n.4. Also of note, it was the United States Court of Appeals for Veterans Claims (the Court) which explained that non-expert witnesses are competent to report that which they have observed with their own senses, as already mentioned above. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Taking Davidson, Jandreau and Layno together, the complexity of the question and whether a nexus opinion could be rendered based on personal observation are factors in determining whether a non-expert nexus opinion or diagnosis is competent evidence. The Veteran’s lay statements essentially assert, as stated at the beginning of this decision, that he visited a radiation site during active service, he developed skin lesions soon after separation as an initial sign of cancer, then later developed cancer in the form of lymphoma, said by his doctor to have manifested at the right time after exposure. Based on this reasoning, the Veteran further asserts the disease should be service-connected. The Veteran’s assertions, without clinical support shown in the record of dose levels high enough to cause radiation-induced disease, as discussed above, and without diagnoses and opinions establishing a causal connection, leave no more than the suggestion that lymphoma was caused by or incurred in active service and therefore only the belief of the Veteran as a lay person that a certain legal conclusion should be reached. The Veteran is competent to report he experienced lymph-node enlargement, back pain, fatigue, fever, and chills associated with lymphoma. However, the inferences he has drawn from what he experienced and observed fall outside the realm of his competency. The record does not indicate he possesses the highly specialized education, training and clinical experience to be able, for example, to interpret the DTRA report referenced by the Director of the Post-9/11 Environmental Health Program to arrive correctly at a higher assigned dose for exposure, nor does he have the knowledge to provide a diagnosis reflecting a causal link between psoriatic lesions and lymphoma or to formulate a rationale for what he reports a physician told him concerning psoriasis being due to exposure, as the physician had no knowledge of what the Veteran’s dose would have been. The Veteran’s inference of causation is therefore not competent evidence but, rather, surmise. Nonetheless, the Veteran’s lay evidence must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. For the reasons stated, the Board ascribes greater probative weight to the examination findings and opinions of the June 2020 memorandum of the Director of the Post-9/11 Environmental Health Program, in the office of the VA Undersecretary for Health, particularly as the findings were prepared by a Health Physicist, with a Bachelor of Science degree (B.S.) and who is a Registered Radiation Protection Technologist (R.R.P.T.). His findings were in turn reviewed by the Director, holding a medical doctor’s degree (M.D.) and a Master’s degree in Public Health (M.P.H.), as well as being a Fellow of the American Academy of Family Physicians (F.A.A.F.P.). Both medical professionals have been certified by appropriate professional bodies in health physics, they objectively reviewed the medical evidence of record, they displayed a thorough knowledge of the Veteran’s medical history, and their conclusions have exhibited consistency and sound clinical judgment. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection on any basis. (Continued on the next page)   The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. M. Miller Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, 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.