Citation Nr: 21073920 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 15-30 151 DATE: December 13, 2021 REMANDED Entitlement to service connection for the cause of the Veteran's death is remanded. REASONS FOR REMAND The appellant is the surviving spouse of a Veteran who served on active duty from May 1967 to March 1969, to include service in the Republic of Vietnam. The Veteran died in April 2013. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision, which denied service connection for the cause of the Veteran's death. In November 2018, March 2021, and August 2021, the Board remanded the claim for additional development. The appellant had asserted that the Veteran's metastatic squamous cell (skin) cancer, which led to his death, was due to his active service. The claims file contains numerous lay statements by the Veteran and fellow soldiers regarding their exposures to herbicide agents, diesel fumes, and human waste in service. It is established, and not in dispute, that during service the Veteran was exposed to herbicide agents and likely also had some exposure to diesel fuel and fumes burning human waste. The Veteran died in April 2013. His death certificate reflects that he died from metastatic squamous cell cancer with no contributory cause of death indicated. The record shows that the Veteran's skin cancer had metastasized to his lungs (and the March 2021 Board decision denied service connection for lung cancer). In response to the August 2021 Board Remand, the VA obtained an addendum opinion regarding the Veteran's cause of death later in August 2021. The examiner identified various risk factors in his opinion, including fair skin, light-colored eyes, red hair, northern European ancestry, older age, childhood freckling, and an increased number of past sunburns. The examiner opined that the type, quantity, and timing of sun exposure associated an increased risk of basal cell, squamous cell carcinomas, MM, and AK are not clearly defined and then states that childhood exposure appears to be more important than exposure during adult life. The examiner identified that the active duty represents only 0.2% lifetime sun exposure and concluded it did not materially contribute to the development of SCC. In an October 2021 appellate brief, the Appellant's representative identified that the evidence of record establishes that the Veteran is of fair skin, which is a risk factor the examiner identified but the report failed to address. Further, the examiner does not identify any evidence of record establishing how much sun exposure the Veteran had as a child, the number of sunburns in-service as compared to before or after, or the effects of the 0.2% had or how much more severe the exposure in service was. Additionally, the Board notes that the Veteran is presumed sound on entry as there is no notations regarding sun burns, sun exposure, or the like. Therefore, this examination is found inadequate for identifying risk factors but failing to address the Veteran's specific facts and circumstances and relying on facts not in evidence. As such, the examiner failed to cite to supporting data as per the Board's August 2021 remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand gives the Veteran a right to compliance with the terms of the remand). The Appellant also identified additional literature that identifies a connection between exposure to the herbicide Agent Orange and skin cancer in the October 2021 appellate brief. The article, "Agent Orange Linked to Skin Cancer, Report Suggests," Science Daily, Wolters Kluwer Health: Lippencott Williams & Wilkens, January 2014. This article identifies a report published in Plastic and Reconstructive Surgery journal regarding additional evidence regarding the risk of non-melanotic invasive skin cancers and increased risk even four decades after Agent Orange exposure. This article has not been addressed by a medical professional in terms of the Veteran and his exposures and risk factors. Therefore, a remand is required for an appropriate clinician to opine on the cited medical evidence. For the above reasons, this matter is remanded for an additional medical opinion. The matters are REMANDED for the following action: 1. The RO should request that the Appellant and/or representative submit a copy of the article "Agent Orange Linked to Skin Cancer, Report Suggests," or the study it is based on, "Association between Agent Orange Exposure and Nonmelanotic Invasive Skin Cancer," to include in the record. The Board notes it was able to access an article with the citation information at https://www.sciencedaily.com/releases/2014/01/140128153812.htm, last visited October 27, 2021. 2. After the above has been completed, arrange for the Veteran's claims file to be forwarded to an appropriate clinician for review and an advisory medical opinion addressing all the remaining medical questions regarding the etiology of the Veteran's metastatic skin cancer. Upon review of the record, the examiner is asked to opine: (a.) whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's metastatic squamous cell carcinoma which led to his death was related to his presumed exposure to herbicide agents; (b.) whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's metastatic squamous cell carcinoma was related to likely exposure to fumes from burning human waste. The clinician shall note that while squamous cell carcinoma is not a disease presumed to be related to exposure to herbicide agents, service connection under that theory of entitlement may nonetheless be established by affirmative competent medical evidence supporting that theory of entitlement. See Combeev. Brown, 34 F.3d 1039 (Fed Cir. 1994). The provider must address the article "Agent Orange Linked to Skin Cancer, Report Suggests," Science Daily, Wolters Kluwer Health: Lippencott Williams & Wilkens, January 2014, and preferably the underlying Plastic and Reconstructive Surgery journal report, "Association between Agent Orange Exposure and Nonmelanotic Invasive Skin Cancer." The opinions provided must include a complete explanation of rationale, with citation to supporting factual data and medical principles. Any identified risk factors must be addressed, including the Veteran's fair skin, and whether this made it more likely that he would incur skin damage in service in the Republic of Vietnam. The rationale should acknowledge and address the significance of, that prior to his death, the Veteran related that he had many skin problems during his active service, and reflect consideration of lay statements by the Veteran fellow soldiers reporting their exposures to herbicide agents and fumes from burning human waste in service. If exposures to herbicide agents and fumes from burning human waste are excluded as etiological factors for development of the metastatic skin cancer, some citation to supporting medical text or treatise would be helpful. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Boushehri, Darjush M. 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.