Citation Nr: 21002872 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 16-34 112 DATE: January 19, 2021 ORDER Entitlement to service connection for breast cancer, to include as due to exposure to JP4 jet fuel is granted. FINDING OF FACT The Veteran’s breast cancer is at least as likely as not etiologically related to active duty service, to include in-service exposure to jet fuel. CONCLUSION OF LAW The criteria for service connection for breast cancer, to include as due to exposure to jet fuel and/or burn pits have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 2003 to November 2007. This appeal was remanded by the Board in February 2020. The Board is now satisfied there was substantial compliance with this Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Specifically, additional medical records were obtained and associated with the claims file, and new VA opinions were obtained, which the Board finds adequate for adjudication purposes. After the required development was completed, this issue was readjudicated and the Veteran was sent a supplemental statement of the case in October 2020. After issuance of this SSOC, another relevant non-VA nexus opinion was added to the record, but not addressed in any readjudication by the AOJ. Nonetheless, given the favorable outcome of this decision, the Board finds that the Remand directives were substantially complied with and, thus, there is no Stegall violation in this case. Entitlement to service connection for breast cancer, to include as due to exposure to jet fuel and/or burn pits The appellant is seeking entitlement to service connection for breast cancer, as due to exposure to jet fuel and/or burn pits as an Army petroleum supply specialist. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Moreover, for such chronic diseases, an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309 (a); See 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2014). In this case, after reviewing all evidence currently of record, the Board determines that service connection for breast cancer is warranted. Specifically, the medical evidence of record preponderates in favor of granting service connection for breast cancer. First, the Veteran’s service treatment records show no treatment for or symptoms of breast cancer in service or at her separation exam, or within the presumptive one-year period after separation. Second, the Veteran has a current disability. Private treatment records indicate the Temple VA medical center (VAMC) referred the Veteran to a private oncologist after an August 2009 abnormal mammogram. The private oncologist diagnosed the Veteran in March 2010 with low grade ductal carcinoma in situ (DCIS) in her left breast with calcifications in her right breast. She subsequently underwent bilateral mastectomies in August 2010. Third, despite the lack of continuous symptoms, the evidence otherwise indicates a relationship between the Veteran’s current disorder and her active duty service. The Veteran advances two theories of direct service connection; her in-service exposure to jet fuel, and her in-service exposure to burn pits. The former is the basis for the Board’s grant herein. The Veteran reported that in service, she was drenched “from the top of her head to her feet” with fuel on 3 occasions, that she was near burn pits of oil and feces, and that her duties to provide fuel on the flight line during her deployment in Iraq and when stationed in the United States exposed her to environmental toxins. The Veteran’s reports of exposure to toxic and environment hazards during service are credible, given her military occupational specialty (MOS) as a fuel supply specialist and her foreign deployment to the Southwest Asia theatre of operations. Her testimony and the evidence are consistent with the places, types and circumstances of her service and her exposure to toxins is therefore recognized. See 38 U.S.C. § 1154(a). The Veteran’s July 2014 examiner discussed the likelihood that the Veteran’s service, particularly her exposure to jet fuel, caused her breast cancer. The examiner noted the Veteran’s symptoms, including swelling numbness and tingling of the left arm, and merely explained that current medical literature did not indicate a link between jet fuel exposure and an increased risk for cancer. Moreover, the examiner reasoned that there was “no increased risk of breast cancer” associated with Gulf War service and that it was less likely than not that the Veteran’s breast cancer was etiologically related to her Gulf War service. This opinion did not expressly discuss possibly carcinogenic components of burn pits or jet fuel. In a December 2014 opinion, a non-VA doctor explained that “although it is possible a cause and effect relationship could exist between the breast cancer and prior exposures [to jet fuel],” the doctor could not identify a direct link between the Veteran’s prior exposure to jet fuel and her breast cancer. The doctor also noted breast cancer was a “common” diagnosis for women with no prior jet fuel exposure and that it was not possible to determine if the Veteran’s exposure caused her cancer. Again, this opinion does not involve substantive discussion of the Veteran’s in-service exposures. Thus, it is speculative and of little probative value. However, a C&P opinion dated April 2020 is of record and expressly discusses the likelihood that the Veteran’s cancer is etiologically related to burn pit exposure. The examiner explained that while toxins in burn pit smoke may cause contact irritation and burning to the skin, eyes, respiratory and cardiovascular systems, gastrointestinal tract and internal organs, current research showed no evidence of long-term health problems from exposure. This medical opinion, offered by a physicians’ assistant, preponderates against service connection. Fortunately, the Veteran was able to obtain a competent, well-reasoned and documented positive nexus opinion in October 2020 from S.B., MD, PhD, an expert in physiology and pharmacology. After exhaustively recounting the Veteran’s diagnosis and treatment, he opined that the Veteran’s breast cancer is at least as likely as not related to her exposure to jet fuel as an Army petroleum supply specialist. This doctor begins by noting that risk factors for the Veteran’s DCIS can include advanced age, family history, a first period before age 12, and certain genetic mutations that increase the risk of breast cancer. As to the Veteran specifically, Dr. B. indicates that her only risk factor is being female. This risk factor, according to Dr. B., is strongly outweighed by her regular exposure to JP4 jet fuel. Dr. B. explains that 72 different chemical compounds go into the manufacture of JP4 – here, the most relevant compound is benzene. Benzene, a dioxin and a common component of Agent Orange, is also heavily present in JP4. Dr. S. cites studies pointing to dioxins interfering with estrogen signaling, which altered mammary gland development in rodents. Thus, dioxin exposure severely multiplied the risk for breast cancer. Further, studies proved that even a brief external exposure can foment a protracted internal exposure. Here, the Veteran competently and credibly recalls being doused in benzene-containing JP4 fuel at least three times. This, according to the research, is more than enough to increase the Veteran’s risk of developing breast cancer. This medical opinion comes from a more qualified perspective, and is based on thorough, well-documented research. Accordingly, its probative value outweighs any negative nexus opinion of record. Therefore, based on this opinion, service connection for breast cancer is warranted. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Z. Maskatia