Citation Nr: 21070835 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 18-00 220A DATE: November 26, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. Entitlement to service connection for pancreatic adenocarcinoma (pancreatic cancer) is denied. FINDINGS OF FACT 1. The Veteran died due to metastatic pancreatic cancer. 2. There is no competent evidence of record that the Veteran suffered from pancreatic cancer during his active service, or that his current disability is related to his active service, or to herbicide agent and Camp Lejeune Contaminated water exposure therein. 3. Though the Veteran was exposed to an herbicide agent and Camp Lejeune contaminated water during his active service, the most probative evidence of record does not reflect that this exposure led to the Veteran's death. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for cause of the Veteran's death have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.312. 2. The criteria for service connection for pancreatic adenocarcinoma (pancreatic cancer), are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.307, 3.309,3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 1964 to August 1966, to include service in the Republic of Vietnam. For his meritorious service, the Veteran was awarded (among other decorations) the Purple Heart Medal and the Vietnam Service Medal. The Veteran died in April 2017; his surviving spouse, the appellant listed above, has been properly substituted in his place. This matter is before the Board of Veterans' Appeal (Board) on appeal from a June 2017 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). The appellant appeared at a hearing before the undersigned Veterans Law Judge in March 2021. A transcript of the hearing is in the Veteran's file. The Board previously remanded the appeal in June 2021, and the matter has been returned for appellate consideration. Specifically, the Board remanded the matter to obtain an additional adequate opinion. As reflected in the discussion section, such an opinion has been obtained, and the Board finds substantial compliance with its remand directives. 1. Entitlement to service connection for the cause of the Veteran's death. 2. Entitlement to service connection for pancreatic adenocarcinoma (pancreatic cancer). The appellant asserts that the Veteran's death is related to his active-duty service. The Veteran died in April 2017. On the Veteran's death certificate, his cause of death was listed as metastatic pancreatic cancer. The appellant contends that the Veteran's pancreatic cancer was a result of his in-service exposure to herbicide agents and contaminated water at Camp Lejeune. To establish service connection for the cause of the Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was either the principal or contributory cause of death. To constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). To be a contributory cause of death, the evidence must show that the service-connected disability contributed substantially or materially to the cause of death, or that there was a causal relationship between the service-connected disability and the Veteran's death. 38 C.F.R. § 3.312(c). To be a contributory cause of death, the service-connected disability must be shown to have combined with the principal cause of death, that it aided or lent assistance to the cause of death. It is not sufficient to show that it casually shared in producing death. A causal relationship must be shown. 38 C.F.R. § 3.312. The question for the Board is whether the Veteran's pancreatic cancer is related to the Veteran's active service, to include exposure to herbicide agents and contaminated water at Camp Lejeune. The Veteran's death certificate reflects a cause of death of metastatic pancreatic cancer. No other causes of death were listed, nor were any other conditions listed as significant or as contributing to the Veteran's cause of death. An October 2018 VA opinion focused on the question of the etiology of the Veteran's bladder cancer. Though that examiner provided a negative opinion, the Veteran was service-connected for his bladder cancer prior to his death. Accordingly, the Board does not find this opinion to be probative as to the question of whether the Veteran's pancreatic cancer was related to his active service. Thus, the June 2021 Board decision remanded the claim for a medical opinion addressing the question of herbicide agent exposure, and the Appellant's contention regarding DDT agent exposure and the development of pancreatic cancer. The July 2021 VA examination report found that the Veteran's pancreatic cancer was unrelated to his in-service herbicide exposure. The VA examiner highlighted that National Academies of Sciences, Engineering, and Medicine 2018 noted that the basis of the evidence reviewed that there is inadequate or sufficient evidence to determine whether there is an association between exposure to chemicals of interest (COI), herbicides and pancreatic cancer. The studies consulted in the study found no statistically significant difference in the incidence of pancreatic cancer between veterans exposed to Agent Orange and the general population not exposed. Additionally, studies also showed no evidence of increased pancreatic cancer rates in civilian workers exposed to herbicide and non-exposed persons. The VA examiner noted that the studies submitted by the Appellant do not specifically mention any linkage between pancreatic cancer and Agent Orange, and that data that those studies are based could be outdated as the data dates to the 1990s. Moreover, the VA examiner found the Veteran's pancreatic cancer unrelated to an in-service exposure to DDT, as the medical studies have not found a statistically significant relationship between DDT and pancreatic cancer. Moreover, literature review regarding the epidemiology of pancreatic cancer does not indicate any toxins or environmental factors other than cigarette smoking as being a risk factor for pancreatic cancer. The VA examiner acknowledged the article submitted by the Appellant that conveyed DDT can cause pancreatic cancer in humans under circumstances of heavy and prolonged exposure. However, the VA examiner highlighted that this level of exposure in the Veteran's circumstance is not likely, as it is claimed he was only serving in an area where DDT was used. The VA examiner also addressed the Appellant's contention that the Veteran's pancreatic cancer must be related to his active service because of the lack of family history of pancreatic cancer. The VA examiner highlighted that only 5 percent to 10 percent of cases of pancreatic cancer have a family history of pancreatic cancer with 90 percent to 95 percent of pancreatic cancer cases. The July 2021 VA examiner also addressed whether the Veteran's pancreatic cancer is related to contaminated water exposure at Camp Lejeune. The July 2021 VA examiner determined the Veteran's pancreatic cancer is unrelated to his in-service exposure to contaminated water. The July 2021 VA examiner noted that the cause of pancreatic cancer is not clear but noted that risk factors include smoking and inherited gene mutations. The VA examiner noted that the Veteran had a long history of smoking was the Veteran greatest risk factor for cancer. The risk of getting pancreatic cancer is about twice as high among smokers compared to non-smokers. The VA examiner also highlighted that the Veteran diagnosis of pancreatic cancer occurred approximately 52 years after his exposure to contaminated water, and a diagnosis of pancreatic cancer would be much sooner than 52 years after past potential exposure. In this case, as to the issues of whether the Veteran's pancreatic cancer is related to his active service, to include exposure to herbicide agents and contaminated water at Camp Lejeune, and whether such exposure is related to the Veteran's cause of death, the Board finds that the July 2021 VA examination report to be adequate and to be the most probative evidence of record as it was definitive, based upon a complete review of the Veteran's entire claims file, in consideration of the Veteran's reported history, prior physical evaluation of the Veteran, and pursuant to the Board's remand instructions. Furthermore, the July 2021 examiner provided a complete and thorough rationale in support of their opinions. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Specifically, the Board acknowledges the appellant's statements regarding the Veteran's death being related to his exposure to an herbicide agent and contaminated water. However, the Board finds that the appellant's testimony alone is not sufficient to establish a nexus between the Veteran's cause of death and his military service. In this regard, the appellant in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the appellant in this case because the record does not show that she has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). To the extent that the appellant has submitted articles regarding a possible link between herbicide agent exposure and the development of pancreatic cancer, those articles were considered by the VA examiner in the adequate and probative opinion of record. Further, those articles on their own are not specific to the Veteran, do not analyze his unique circumstances and history, and are therefore not an adequate basis on which to grant service connection alone. The appellant submitted a previous Board decision in which service connection was granted for pancreatic cancer as due to herbicide agent exposure. While the Board strives for consistency across its decisions, the Board's decisions are not precedential. Further, the difference between the decision submitted by the appellant and the case before the Board currently is that, in the decision submitted, the appellant there furnished competent evidence in support of his or her claim in the form of private opinions. Here, the only opinions of record weigh against the appellant's claim. Finally, the Board acknowledges that the Veteran was service-connected for bladder cancer prior to his death. There is no evidence, however, that the Veteran's pancreatic cancer is related to or had metastasized from his service-connected bladder cancer. The private and VA treatment records reflect that the Veteran's pancreatic cancer was a primary cancer, and there is no evidence of a relationship between that cancer and any of the Veteran's service-connected disabilities. In the end, the Board concludes that the most probative, competent evidence of record indicates that the Veteran's in-service herbicide agent and contaminated water exposure did not lead to pancreatic cancer, and therefore is unrelated to his death. The weight of the evidence is against the claim, and there is no doubt to be resolved. Service connection for pancreatic cancer and for the cause of the Veteran's death is therefore denied. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.R. Higgins 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.