Citation Nr: 21071014 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 17-45 608 DATE: November 29, 2021 ORDER Entitlement to service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected chronic lymphocytic leukemia, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina, is denied. FINDINGS OF FACT 1. The record evidence shows that the Veteran had active combat service in the Republic of Vietnam; thus, his in-service exposure to an herbicide agent is presumed. 2. The record evidence shows that the Veteran served at Camp Lejeune, North Carolina, from approximately November 1963 to March 1966; thus, his in-service exposure to contaminated water at Camp Lejeune, North Carolina, is presumed. 3. The record evidence shows that service connection is in effect for chronic lymphocytic leukemia (CLL). 4. The record evidence shows that the Veteran's current skin disability, to include skin cancer and seborrheic keratosis, is not related to active service or any incident of service, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. CONCLUSION OF LAW The criteria for service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected chronic leukocytic leukemia, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina, have not been met. 38 U.S.C. §§ 1110, 1154, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active service from August 1963 to August 1967, including in combat in the Republic of Vietnam. He died in November 2016. The Appellant is his surviving spouse and substitute claimant in this appeal. This appeal has a long procedural history. It comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision which denied, in pertinent part, the currently appealed claim. A virtual Board hearing was held in February 2021 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. In March and July 2021, the Board remanded the currently appealed claim to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed that the AOJ obtain an addendum opinion concerning the nature and etiology of the Veteran's skin disability, to include skin cancer and seborrheic keratosis. This opinion was obtained in September 2021. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Having reviewed the record evidence, the Board finds that the issue on appeal should be characterized as stated above. Because the Appellant currently lives within the jurisdiction of the Regional Office (RO) in Denver, Colorado, that facility has jurisdiction in this appeal. Entitlement to service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected chronic leukocytic leukemia, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina The Board finds that the preponderance of the evidence is against granting the claim of service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected chronic leukocytic leukemia, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. The Veteran, prior to his death, and the Appellant, after the Veteran's death, essentially contend that he incurred a skin disability, to include skin cancer and seborrheic keratosis, during active service and experienced continuous post-service disability. They alternatively contends that the Veteran's service-connected chronic lymphocytic leukemia (CLL) caused or contributed to his skin disability, to include skin cancer and seborrheic keratosis. They also alternatively contend that the Veteran's in-service exposure to an herbicide agent while in Vietnam or in-service exposure to contaminated water at Camp Lejeune, North Carolina, caused or contributed to his skin disability, to include skin cancer and seborrheic keratosis. The record evidence does not support the lay assertions concerning an etiological link between a skin disability, to include skin cancer and seborrheic keratosis, and active service or any incident of service, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. It shows instead that, although the Veteran was diagnosed as having and treated for skin cancer and seborrheic keratosis prior to his death, this disability is not related to active service and was not caused or aggravated by his service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. The Board notes initially that, because the Veteran's available service personnel records show that he served in combat in Vietnam, his in-service exposure to an herbicide agent is presumed. See 38 C.F.R. § 3.307(a)(6) (2020). Although the Veteran likely was exposed to an herbicide agent during his honorable active combat service in Vietnam, the Appellant does not contend and the record evidence does not show that he was diagnosed as having or treated for a skin disability such as chloracne or soft-tissue sarcoma for which service connection is available on a presumptive basis due to in-service exposure to an herbicide agent. See 38 C.F.R. § 3.309(e) (2020). In other words, service connection is not available for either skin cancer or seborrheic keratosis on a presumptive basis due to in-service exposure to an herbicide agent. Id. Thus, the Board finds that service connection for a skin disability, to include skin cancer and seborrheic keratosis, as due to in-service exposure to an herbicide agent, is not warranted on a presumptive basis. Id. The Veteran also is not entitled to service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina, on a direct basis. See 38 C.F.R. §§ 3.303, 3.304. The Board notes initially that, because his service treatment records show that he served at Camp Lejeune, North Carolina, from approximately November 1963 to March 1966, his in-service exposure to contaminated water at this facility is presumed. See 38 C.F.R. § 3.307(a)(7) (2020). Contrary to the lay assertions and Board hearing testimony of record, the service treatment records show instead that, on enlistment physical examination on August 1, 1963, clinical evaluation of the Veteran was normal. On reexamination on August 15, 1963, which was listed as the "effective date of enlistment," no defects were noted. He denied all relevant pre-service medical history. On reexamination on August 19, 1963, tinea corporis was noted in the list of defects. At his separation physical examination in August 1967, clinical evaluation was normal. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The post-service also does not support granting service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. Contrary to the lay assertions and Board hearing testimony, the record evidence shows that the Veteran's skin disability, to include skin cancer and seborrheic keratosis, is not related to active service or any incident of service. It also shows that his conceded in-service exposure an herbicide agent, in-service exposure to contaminated water at Camp Lejeune, North Carolina, and his service-connected CLL did not cause or contribute to his skin disability, to include skin cancer and seborrheic keratosis. For example, in a February 2014 opinion, a VA clinician opined that it was less likely than not that the Veteran's skin disability is related to active service or any incident of service. The rationale for this opinion was based on a review of the claims file which showed that he was diagnosed as having tinea corporis during service. The rationale also was, "Tinea corporis is a fungal rash most common on the torso and not common on the extremities whereas the current rash is only on the" extremities. The rationale further was that the Veteran reported that his current skin rash only began several years after his service separation. "Neither its appearance nor temporal occurrence is suspicious for tinea so the current eczema is less likely than not related to military service." In an April 2015 opinion, a VA clinician opined that it was less likely than not that the Veteran's skin cancer (which was characterized as superficial basal cell cancer) is related to active service, including as due to in-service exposure to an herbicide agent or in-service exposure to contaminated water at Camp Lejeune, North Carolina. The rationale for this opinion was based on a review of the claims file and relevant medical literature. The rationale also was, "The leading known risk factor [for skin cancer] is sun exposure, a risk factor in both places the Veteran resides" in Florida and Colorado. In an August 2016 opinion, a VA clinician opined that it was less likely than not that the Veteran's skin cancer is related to active service or any incident of service, including as due to his service-connected CLL. The rationale for this opinion was based on a review of the claims file and relevant medical literature. The rationale also was: CLL is not known to directly cause Skin Cancer, but is known to be associated with an increased risk of developing a second cancer, most likely due to a shared risk factor of general immune suppression. In the Veteran's history, however, the superficial basal cell skin cancer preceded his CLL. The skin cancer was identified a year before the diagnosis of CLL. Therefore, CLL did not result in development of the Veteran's superficial basal cell skin cancer. Although some chemotherapy medications are known to result in immune-suppression, which in turn results in increased risk for skin cancer, the Veteran's CLL has not been treated with immune-suppressing chemotherapy (or any other medication). As noted in prior opinions, the Veteran's male gender, his age, and his history of residence in Florida and Colorado (high sun-exposure states) are the most likely etiology for this Veteran's skin cancer noted in the record in 2011. The Board notes that, because it previously found that a March 2021 VA medical opinion was inadequate for VA adjudication purposes in the July 2021 remand, this opinion was not reviewed or relied upon in adjudicating the currently appealed claim. In a September 2021 opinion, a VA clinician opined that it was less likely than not that the Veteran's service-connected CLL caused or aggravated his skin disability, to include skin cancer and seborrheic keratosis. The rationale for this opinion was based on a review of the claims file. The rationale also was: There is no anatomic or pathophysiologic mechanism by which CLL can impact unspecified skin cancers and seborrheic keratoses. Furthermore, there is no evidence of aggravation of either condition beyond their natural course due to any cause. Skin cancers are generally due to lifetime sun exposure, family history, skin type, skin color (not necessarily racial difference), race and other factors. CLL would neither cause nor aggravate the condition. Seborrheic keratosis is thought to be autoimmune, possibly due to local irritants. There is no evidence of aggravation beyond the natural course and there is no anatomic or pathophysiologic mechanism by which CLL can impact seborrheic keratosis. Therefore, it is less likely than not that the Veteran's skin cancer (not specified) are seborrheic keratosis and then aggravated on their natural course due to any cause, including...CLL. An individual with skin cancer generally has areas of significant solar damage which leads to precancerous changes ultimately followed by skin cancers. Despite the lay assertions and Board hearing testimony to the contrary, the record evidence shows instead that the Veteran's skin disability, to include skin cancer and seborrheic keratosis, is not related to active service or any incident of service, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. Although the record evidence shows that the Veteran likely was exposed to an herbicide agent while in combat in Vietnam, he was not diagnosed as having a skin disability for which service connection is available on a presumptive basis due to such exposure. And the evidence does not support finding an etiological link between his conceded in-service exposure to an herbicide agent and his skin disability on a direct basis. Similarly, although the record evidence shows that the Veteran likely was exposed to contaminated water at Camp Lejeune, and although service connection is in effect for CLL, neither this conceded exposure nor service-connected CLL caused or aggravated the Veteran's skin disability, to include skin cancer and seborrheic keratosis. Multiple VA clinicians opined in February 2014, April 2015, August 2016, and in September 2021 that there was no etiological link between in-service exposure to an herbicide agent, in-service exposure to contaminated water at Camp Lejeune, or service-connected CLL and the Veteran's skin disability, to include skin cancer and seborrheic keratosis. All of these opinions were fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Neither the Veteran, prior to his death, nor the Appellant, since the Veteran's death, has identified or submitted any evidence demonstrating entitlement to service connection for the Veteran's skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina. In summary, the Board finds that service connection for a skin disability, to include skin cancer and seborrheic keratosis, including as due to service-connected CLL, in-service exposure to an herbicide agent, or in-service exposure to contaminated water at Camp Lejeune, North Carolina, is not warranted. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael T. Osborne, 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.