Citation Nr: 21062043 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 10-21 353 DATE: October 6, 2021 ORDER Entitlement to service connection for Hodgkin's lymphoma to include as a result of exposure to chemical substances in the water at Camp Lejeune is denied. FINDING OF FACT The preponderance of the evidence is against finding that Hodgkin's lymphoma began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a Hodgkin's lymphoma are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1972 to July 1974. He also had additional periods of service with the Army National Guard from May 1989 to May 1992 and from May 2001 to August 2003, and with the Navy Reserves from May 1992 to June 1994. The Board denied the claim in a December 2011 decision which the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). The Court granted a Joint Motion for Partial Remand (JMPR) in March 2013. The Board remanded the claim for further development several times, most recently in August 2020. There has been substantial compliance with the remand directives and the Board will proceed with adjudication. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for Hodgkin's lymphoma to include as a result of exposure to chemical substances in the water at Camp Lejeune The Veteran asserts that his Hodgkin's lymphoma is due to exposure to chemicals in the water at Camp Lejeune. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of Hodgkin's lymphoma, was presumed to have been exposed chemicals at Camp Lejeune, the preponderance of the evidence weighs against finding that the Hodgkin's lymphoma began during service or is otherwise related to an in-service injury, event, or disease. If a Veteran served at Camp Lejeune, during the time frame specified, certain diseases shall be service-connected even though there is no record of such disease during service. 38 C.F.R. § 3.309 (f). The diseases listed in §3.309(f) shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307 (a)(7)(ii). Although non-Hodgkin's lymphoma is listed among the diseases listed in 38 C.F.R. § 3.309(f), Hodgkin's lymphoma is not. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), (f). The Veteran may still establish service connection through evidence showing direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Board's analysis will be on direct causation. The Board previously remanded the claim because VA medical opinions were inadequate; those opinions will be not be discussed further. In September 2020 and January 2021 opinions, a VA occupational medicine specialist concluded that the Veteran's Hodgkin's disease is not at least as likely as not related to his service, including exposures to chemicals at Camp Lejeune. The occupational medicine specialist detailed the Veteran's history, noting he was diagnosed with Hodgkin's disease in 2004, 30 years after his service at Camp Lejeune. In the rationale, the examiner specifically reviewed the Center for Disease Control (CDC) report, and included additional citations to over 50 separate pieces of medical literature. The examiner specifically discussed the CDC report, "Trichloroethylene and Cancer: Epidemiologic Evidence," by Daniel Wartenberg, Daniel Reyner, and Cheryl Siegel Scott. The examiner observed that the article was published "some time ago" in 2000. The examiner stated the following: This article is a cumulative review of over 80 articles, papers and letters on the cancer epidemiology of people exposed to trichloroethylene. Results showed, based on analysis of these papers and reports that "excess cancer incidence" is noted to be present based on the most rigorous exposure assessment for kidney cancer and liver cancer and non-Hodgkin's lymphoma. Also notable were findings of excessive cancer incidence for cervical cancer, Hodgkin's disease and multiple myeloma. In this instance, claimant was suffering from Hodgkin's disease. The article goes on to note that in this analysis, "few studies isolate trichloroethylene exposures," and thus results are likely confounded by exposure to other solvents and other risk factors (such as tobacco smoking, alcohol use and many others). Data was also notable in that methods, duration, concentration, etc. of exposure of chemicals varies from study to study. Overall number of subjects with the diseases under study also can skew results. Reviewers note that for Hodgkin's disease studies were not consistent; some studies showed excess incidence and some studies show no such findings. Thus, taken together, while this article is notable for findings, the authors "recommend further study to better specify the specific agents that confer (the) risk and to estimate the magnitude of that risk." Therefore, this article shows, with major caveats and limitations, some data suggesting an increase in Hodgkin's disease developing from those exposed to TCE (within the parameters identified in the literature reviewed). It does not in any way support that the potential exposures that the claimant had at Camp Lejeune has led to him developing Hodgkin's disease. A January 2021 medical opinion provided by a different physician included a review of the CDC information. The examiner noted that the article found that evidence of excess cancer incidence among occupational cohorts with the most rigorous exposure assessment is found for kidney cancer, liver cancer and non-hodgkin's lymphoma, as well as for cervical cancer, Hodgkin's disease, and multiple myeloma. "However, since few studies isolate trichloroethylene exposure, results are likely confounded by exposure to other solvents and other risk factors. (https://pubmed.ncbi.nlm.nih.gov/10807550/). Hodgkin is not included in the list provided by ATSDR with sufficient evidence for causation. No other literature is found that specifically states that hodgkin lymphoma is causally related to exposure to contaminants in the Camp Lejeune." Therefore, it was this examiner's opinion that it is less likely than not that the Veteran's Hodgkin's lymphoma is related to his service. The examiners' combined opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran believes his Hodgkin's lymphoma is related to service; however, he is not competent to provide a nexus opinion regarding this issue. The diagnosis and etiology of the disease involves complex medical issues that go beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board gives more probative weight to the September 2020 and January 2021 VA examiner's opinions. As the preponderance of the evidence is against the claim, service connection is denied. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.