Citation Nr: 21006561 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 17-38 116 DATE: February 4, 2021 ORDER Service connection for pancreatic cancer is granted. FINDING OF FACT The Veteran’s pancreatic cancer was caused by the service-connected diabetes mellitus. CONCLUSION OF LAW Resolving reasonable doubt in the appellant’s favor, the criteria for service connection for pancreatic cancer have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1970 to July 1972. The Veteran died in February 2019. The appellant is the Veteran’s surviving spouse, who has been substituted in this claim. 38 U.S.C. § 5121A. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision from the Regional Office (RO), which denied service connection for pancreatic cancer. The Veteran initially requested a travel Board hearing on the August 2017 substantive appeal; however, in written correspondence submitted July 2018, the Veteran withdrew the hearing request. 38 C.F.R. § 20.704(e). This case was previously before the Board in August 2018, where the issue on appeal was remanded to obtain outstanding private treatment records, VA treatment records, and a medical opinion from a VA examiner. While cognizant of its responsibilities under Stegall v. West, 11 Vet. App. 268 (1998), as the Board grants service connection for the pancreatic cancer, which is a total grant of benefits as to the issue on appeal, the Board need not address Stegall compliance at this time. Service Connection for Pancreatic Cancer Under the relevant laws and regulations, service connection may also be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(c). During his lifetime, the Veteran asserted that service connection for prostate cancer was warranted as due to the service-connected diabetes mellitus or as due to herbicide agent exposure during service. See April 2016 Notice of Disagreement (NOD), April 2018 Correspondence. A November 2015 rating decision granted service connection for diabetes mellitus. Private treatment records dated from June 2014 through 2018 show that the Veteran was diagnosed with and underwent treatment for pancreatic cancer, to include chemotherapy and surgery. See June 2014, August 2014, July 2018 private treatment records. After reviewing all the evidence, both lay and medical, the Board finds that the evidence is in equipoise on the question of whether pancreatic cancer was caused by the service-connected diabetes mellitus. In November 2020, the VA examiner opined that it was less likely than not that pancreatic cancer was caused by the service-connected diabetes mellitus. The VA examiner noted that the diagnosis of diabetes was made around 2006 and acknowledged that long-standing diabetes is a risk factor for the development of pancreatic cancer. However, the examiner noted that the stronger link is for pancreatic cancer to interfere with glucose metabolism and cause the de novo onset of diabetes. The examiner noted that risk does not imply cause and the Veteran had a 60 pack-year history of smoking, which is the highest level risk, along with genetic predisposition. Additionally, the current, widely accepted, peer-reviewed literature has not established type II diabetes as a cause of pancreatic cancer. Therefore, it is less likely than not that the veteran's pancreatic cancer is due to or caused by diabetes. See November 2020 VA examination report. However, a review of the record shows that the Veteran was not diagnosed with diabetes mellitus until August 2009, not 2006. As such, diabetes was first diagnosed within five years of the diagnosis of pancreatic cancer in June 2014. Additionally, the Veteran, who was a thoracic physician, and his treating oncologist, Dr. Yuan, both opined that it is more likely than not that the pancreatic cancer was caused by the service-connected diabetes mellitus, noting that the medical literature does support a link between pancreatic cancer and prostate cancer. In support of the opinions the physicians provided medical literature that indicates that pancreatic cancer is a likely cause of diabetes in individuals who are diagnosed with pancreatic cancer within two years before diagnosis of pancreatic cancer; however, studies have also indicated a causal link between longstanding diabetes and the development of pancreatic cancer. Specifically, studies have shown than individuals diagnosed with diabetes less than five years before their pancreatic cancer diagnosis, as is the case in this matter, had a 50 percent greater risk of pancreatic cancer than did those diagnosed with diabetes more than 5 years before their cancer diagnosis. Additionally, studies have shown that longstanding diabetes mellitus is associated with a 1.5 to 2.0 fold increase in the risk of pancreatic cancer. Moreover, while other risk factors for pancreatic cancer included smoking and a family history of pancreatic cancer, the evidence does not show that the Veteran has a family history of pancreatic cancer, and the evidence indicates that the Veteran stopped smoking in 1984, 30 years before the pancreatic cancer diagnosis. The Veteran referenced medical literature that indicates that the risk for pancreatic cancer declines to that of a never-smoker upon abstaining from smoking for 20 years. See June 2016, January 2018, December 2018 Correspondence; April 2018 private treatment record; January 2021, July 2018 representative brief. The death certificate indicates that the Veteran’s cause of death was metastatic pancreatic cancer, and diabetes mellitus was listed as a significant condition that contributed to the cause of death. Based on the above, and resolving reasonable doubt in favor of the appellant, service connection for a pancreatic cancer, as secondary to the service-connected diabetes mellitus, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The grant of secondary service connection renders moot other theories of service connection. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Moore 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.