Citation Nr: 21061713 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 17-62 828 DATE: October 5, 2021 REMANDED Entitlement to service connection for Parkinson's disease of the right hand is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1956 to December 1959. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision. In September 2017, an informal conference was held before a Decision Review Officer (DRO) at the Regional Office (RO); a summary is in the record. In April 2019, a videoconference hearing was held before the undersigned; a transcript is in the Veteran's record. In May 2019, the case was remanded for additional development. Unfortunately, the Veteran died in March 2020, during the pendency of this appeal. The Regional Office (RO) has recognized his widow as the substitute claimant for the purpose of processing this claim to completion. See July 1, 2020 VA correspondence. In February 2021 and June 2021, the appeal was remanded for additional development. Entitlement to service connection for Parkinson's disease of the right hand The Board is aware that this matter was remanded before (and regrets the delay inherent with another remand); but because there was not substantial compliance with previous remand instructions, another remand is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board remanded this matter in June 2021 for an advisory medical opinion addressing whether the Veteran's Parkinson's disease (PD) was caused or aggravated by his service-connected residuals of renal cancer, status post left kidney removal (including the treatment he received for such). Notably, the appellant's representative raised this (alternative) secondary service connection theory of entitlement in a May 2021 brief, and cited to a National Library of Medicine, National Institutes of Health article pertaining to associations between Parkinson's disease and cancer; she specifically quoted the following, "In two Taiwanese and British cohort studies, brain, kidney, and uterine cancers were positively associated with PD after diagnosis." In July 2021, a VA Advanced Practice Registered Nurse (APRN) reviewed the record and provide a negative secondary service connection opinion. She explained that "PD and cancer are not at all similar, and can even be thought of as biomechanically opposite in one disease (PD), cells die unexpectedly and in the other (cancer), cells divide too often and are perpetuated for too long. In fact, there have been many epidemiological studies over the past decades that have shown that patients who have had cancer have a lower risk of developing PD than the general population." She continued to explain that research suggests that the relationship between cancer and PD "may differ in different ethnic populations." For example, she cited to a 2015 study which showed an increased risk of cancer among persons of Chinese heritage with PD. Acknowledging the articles submitted by the appellant, the APRN wrote, "Although overlap between PD and cancer is becoming evident, there are several concerns stemming from some of the contradictory results on both the epidemiological and laboratory fronts. Studies have traditionally seen a decrease in cancer ris[k] associated with parkinson's disease, and the increased risk noted is not found to be related to renal cell cancer, from what was reviewed it is felt the relationship may be due to genetic mutations or other complex interplay. The Board finds the opinion inadequate for two reasons. First, the rationale provided contains internally inconsistent and speculative statements. It states that "overlap between PD and cancer is becoming evident" but concludes that the Veteran's PD is not found to be related to renal cell cancer; it also states that the relationship "may be due to genetic mutations or other complex interplay" (emphasis added), suggesting the etiology is unknown. Second, the rationale does not address whether the Veteran's PD was aggravated by his service-connected renal cell cancer residuals (including the treatment for such), as directed by the Board's remand. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-141 (2013) (findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation). Accordingly, development for a fully adequate addendum advisory medical opinion is necessary. Stegall, 11 Vet. App. at 271. The matter is REMANDED for the following: Arrange for the Veteran's record to be returned to the June 2021 consulting APRN for an addendum advisory medical opinion regarding the likely etiology of his Parkinson's disease. [If that provider is unavailable or unable to provide the addendum opinion sought, arrange for the record to be forwarded to another appropriate clinician for review and the opinions sought.] The consulting provider should provide opinions that respond to the following: (a) Is it at least as likely as not (a 50% or greater probability) that the Veteran's Parkinson's disease of the right hand was caused or aggravated by his service-connected residuals of renal cancer, status post left kidney removal (including the treatment he received for such)? [The opinion must specifically address aggravation.] The rationale for the opinion should discuss the NIH treatise article cited by the appellant in her May 2021 brief (including the notation that, "In two Taiwanese and British cohort studies, brain, kidney, and uterine cancers were positive associated with PD after diagnosis..." [emphasis added]), and apply the medical evidence of record in this case to this theory of entitlement. (b) If the response to (a) is No, identify the etiology of the Veteran's PD that is considered to be more likely (and explain why that is so). The consulting provider must include rationale with all opinions, citing to supporting factual data and medical principles as deemed appropriate. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dupont, 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.