Citation Nr: 21006070 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 16-56 057 DATE: February 3, 2021 ORDER Entitlement to service connection for pancreatic cancer, to include as due to asbestos exposure, is denied. FINDING OF FACT 1. The preponderance of the evidence is against finding that pancreatic cancer began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for pancreatic cancer are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from December 1958 to March 1962, and as a shipfitter in the United States Navy from May 1963 to May 1967. He died in 2015, and the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the appellant testified before the undersigned during a videoconference hearing. A transcript of the hearing is included in the electronic claims file. In December 2019, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to send the claimant an accurate VCAA letter and then to obtain a VA examination. The VCAA letter was sent in February 2020 and the RO obtained a series of VA examinations in May, June, July, and August of 2020. An August 2020 VA examination found that the Veteran’s liver cancer condition metastasized from his primary cancer of cholangiocarcinoma, which was due to his asbestos exposure. As a result, the claimant was granted service connection for cholangiocarcinoma with metastasis to liver effective October 9, 2015 in a September 2020 rating decision. The claimant was also granted service connection for cause of death and for cholestasis in the same decision. As such, the issues of service connection for liver cancer and the Veteran’s cause of death are no longer on appeal. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a “service connection.” 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, Service Connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service – the so-called “nexus” requirement. Holton v Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Furthermore, in deciding whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2014); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. Entitlement to service connection for pancreatic cancer, to include as due to asbestos exposure. The claimant asserts that her husband died as a result of pancreatic cancer he developed as a result of asbestos exposure as a Navy shipfitter. The Veteran’s death certificate, as conceded by the RO in an April 2016 rating decision, found that the Veteran’s primary cause of death was liver failure caused by pancreatic cancer. Likewise, the RO conceded asbestos exposure in a September 2020 rating decision based on the Veteran’s Navy service as a shipfitter/pipefitter. As a result, the first and second elements of service connection have been met. The claim rests on whether there is a nexus between the Veteran’s pancreatic cancer and his in-service asbestos exposure. Unfortunately, there is no link between his pancreatic cancer and service. Three VA examinations of the Veteran’s medical history were completed in March 2020, June 2020, and July 2020. The March 2020 VA examiner concluded that the “Medical literature does not support asbestos exposure as a cause of pancreatic cancer.” The examiner explained that there were environmental factors, which asbestos was not, and hereditary factors that contribute to the development of pancreatic cancer. The Veteran had several hereditary factors, including diabetes, hypertension, hyperlipidemia, and a history of smoking. However, the examiner failed to address the medical literature submitted by the claimant’s representative. The claimant’s representative submitted the following medical literature in support of the claim: Residential Proximity to Naturally Occurring Asbestos and Mesothelioma Risk in California; Translocation of Inhaled Asbestos Fibers from the Lung to Other Tissues; Occupational Exposures and Pancreatic Cancer: a Meta-Analysis; Asbestos in Drinking Water and Cancer Incidence in the San Francisco Bay Area; A Historical Cohort Mortality Study of Workers Exposed to Asbestos in a Refitting Shipyard. The December 2019 remand instructed the VA examiner to address each article. The June 2020 examiner stated, “After reviewing the articles provided and considering the veterans MOS, it is at least as likely as not that the veterans pancreatic cancer, which metastasized to the liver, was due to asbestos exposure in service.” However, no rationale was provided to explain this opinion and so the RO obtained another medical opinion in July 2020. The July 2020 examiner concluded that it was less likely than not that “the [Veteran’s] pancreatic cancer and subsequent liver failure due to pancreatic cancer were proximately due to or the result of asbestos exposure during service.” The examiner explained that while VA guidelines associate asbestos exposure with certain types of cancers, “asbestos exposure is at this time not a medically recognized risk factor for or cause of pancreatic cancer.” Specifically, in connection to gastrointestinal (GI) cancer, the examiner stated, “Asbestos as a risk factor for GI cancers is strongest for stomach cancer though the study results are inconsistent and the association weak.” The examiner then addressed the medical literature submitted by the claimant. They explained that the article, Residential Proximity to Naturally Occurring Asbestos and Mesothelioma Risk in California, “used pancreatic cancer patients as a control when evaluating mesothelioma due to asbestos exposure in drinking water and so does not address his claim for causation of pancreatic cancer by asbestos exposure.” The next article, Translocation of Inhaled Asbestos Fibers from the Lung to Other Tissues, “discussed that [asbestos] fibers may migrate to other tissues including the pancreas, but did not indicate that the asbestos fibers caused pathology in those other tissues.” The article, Asbestos in Drinking Water and Cancer Incidence in the San Francisco Bay Area, “concluded that there was an increased risk of pancreatic cancer in those exposed to asbestos contaminated drinking water, an exposure source not likely with pipe fitting and not claimed.” The examiner explained that the ingestion of asbestos in the study was not comparable to the situation here where the asbestos was allegedly inhaled. The examiner found that the fourth article, A Historical Cohort Mortality Study of Workers Exposed to Asbestos in a Refitting Shipyard, was the closest to the Veteran’s situation. However, that study used shipyard workers with long-term asbestos exposure, which is considered to be at least 10 years. Here, the Veteran was a shipfitter for only four years. Furthermore, the examiner stated that this study was “contradicted by another shipyard study that did not find an increased incidence of pancreatic cancer among those exposed to [asbestos].” The article, Occupational Exposures and Pancreatic Cancer: a Meta-Analysis, was cited by the examiner in his literature review which stated that, “Occupational exposures may increase risk of pancreatic cancer[, but] High quality studies are called for on interactions between occupational, environmental, and lifestyle factors as well as interactions between genes and the environment.” The examiner further stated that the Veteran “had a history of cigarette smoking, diabetes, insulin resistance, and obesity all of which are medically accepted risk factors for the development of pancreatic cancer.” See July 2020 VA Examination. An August 2020 VA examination found that the Veteran’s liver cancer condition metastasized from his primary cancer of cholangiocarcinoma, which was due to his asbestos exposure. As a result, the Veteran was granted service connection for cholangiocarcinoma with metastasis to liver effective October 9, 2015. The medical evidence of record fails to establish a nexus between the Veteran’s pancreatic cancer and his active duty service. As a result, the claim is denied. In reaching this decision, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Johnston, 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.