Citation Nr: 21062781 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 19-09 554 DATE: October 12, 2021 ORDER Entitlement to service connection for prostate cancer is granted. Entitlement to service connection for erectile dysfunction, secondary to service-connected prostate cancer on a causation basis, is granted. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's prostate cancer is related to his service. 2. The Veteran's erectile dysfunction is a result of his prostate cancer. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for prostate cancer are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for erectile dysfunction secondary to prostate cancer have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1979 to February 1982. This case comes to the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to service connection for prostate cancer and erectile dysfunction. In November 2017 the Veteran filed a notice of disagreement (NOD) and in February 2019 the RO issued a statement of the case (SOC). In April 2019 the Veteran filed a substantive appeal (via VA Form 9). In September 2021 the Veteran testified during a virtual hearing before the undersigned Veterans Law Judge (VLJ). The hearing transcript is not currently associated with the record, however, as the Board is granting the benefit sought in full, a transcript of that hearing is not warranted. 1. Prostate cancer The Veteran contends that he is entitled to service connection for prostate cancer which was caused by his exposure to contaminated water while he was stationed at Camp Lejeune. Service connection may be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds (VOCs), trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service at the United States Marine Corps Base Camp Lejeune and/or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7). The following diseases are deemed associated with exposure to contaminated water at Camp Lejeune: kidney cancer, liver cancer, Non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309(f). Prostate cancer is not among the diseases for which VA has specifically determined a presumption of service connection is warranted. As a result, entitlement to service connection on a presumptive basis based on exposure to contaminated water at Camp Lejeune is not warranted. Nevertheless, consideration of whether a grant of service connection on a direct basis is still necessary in this case. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994) (when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis). Service connection will be granted on a direct basis if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In April 2015 a private physician filled out a prostate cancer disability benefits questionnaire (DBQ) and noted that the Veteran was diagnosed with prostate cancer and impotence of organic origin. The Veteran underwent a prostatectomy on April 16, 2015. Thus, a current disability has been demonstrated. As to the in-service injury or disease element, a veteran who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987 shall be presumed to have been exposed during such service to water contaminated with volatile organic compounds (VOCs) during such service, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. 38 C.F.R. § 3.307(a)(7). The Veteran's service personnel records reflect that he was stationed at Camp Lejeune for at least 30 days during service. Therefore, he is presumed to have been exposed to water contaminated with VOCs and has met the in-service disease or injury requirement. The Board notes that the Veteran's military occupational specialty (MOS) was a hygiene equipment operation and would have extensive exposure to water while stationed at Camp Lejeune. The remaining question is whether a nexus exists between the Veteran's current prostate cancer and an in-service injury or disease. In a May 2015 letter, the Veteran's private physician opined that the Veteran's prostate cancer was at least as likely as not caused by exposure tetrachlorethylene and benzene. The private physician explained that exposure to these chemicals can be linked to esophagus, kidney, cervix, and bladder cancer. Also, the private physician explained that benzene is carcinogenic to humans and numerous studies link tetrachlorethylene and benzene to prostate cancer. While the private physician relied on the service history provided by the Veteran, the discounting of a medical opinion that relied on service history provided by the Veteran is only warranted in certain circumstances, none of which are present here. See Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006) (reliance on the service history provided by the veteran only warrants the discounting of a medical opinion in certain circumstances, such as when the opinions are contradicted by other evidence in the record or when the Board rejects the statements of the veteran). Although the private physician's rationale was not extensive, reading the opinion as a whole and in the context of the evidence of record, it is entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). A November 2016 VA examiner opined that the Veteran's prostate cancer was less likely than not caused by or the result of the Veteran's exposure to contaminated water at Camp Lejeune. The VA examiner explained that risk factors for prostate cancer include increasing age, ethnicity, and use of tobacco. The VA examiner acknowledged that there may be an increased risk of developing prostate cancer associated with tetrachloroethene but stated that this would have been greater than the Veteran's estimated exposure to this chemical at Camp Lejeune. The VA examiner concluded that given the Veteran's age, ethnicity, and use of tobacco, along with his limited exposure to contaminated water at Camp Lejeune, it is less likely that his prostate cancer can be linked to his military service. As the November 2016 VA examiner did not address the positive opinion from the Veteran's private physician, relied on outdated medical studies, and did not appropriately account for the Veteran's extensive exposure to contaminated water as a hygiene equipment operator, his opinion is entitled to no probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Given the Veteran's presumed exposure to contaminated water at Camp Lejeune, the positive nexus opinion, and the flawed negative nexus opinion, entitlement to service connection for prostate cancer is warranted on a direct basis. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's prostate cancer was caused by his exposure to contaminated water while stationed at Camp Lejeune. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for prostate cancer is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Erectile dysfunction secondary to prostate cancer Service connection may also be granted for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). As of now the Veteran is service connected for prostate cancer and a connection between the Veteran's current erectile dysfunction and his service-connected prostate cancer is the remaining dispositive issue. The private physician who filled out the April 2015 DBQ did not expressly provide an opinion as to whether the Veteran's erectile dysfunction is secondary to his service-connected prostate cancer on a causation or aggravation basis. However, the treatment note makes clear that the Veteran's erectile dysfunction is associated with the Veteran's prostate cancer and read in context of the medical records, implicitly indicates that the Veteran's prostate cancer caused the Veteran's erectile dysfunction. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran's erectile dysfunction was caused by his service-connected prostate cancer. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the criteria for service connection for erectile dysfunction are met and service connection for this disability is warranted on a secondary, causation basis. 38 U.S.C. §§ 5107(b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Miller, 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.