Citation Nr: 21006809 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 19-32 547 DATE: February 5, 2021 ORDER Entitlement to service connection for myelodysplastic syndrome (MDS) is granted. FINDINGS OF FACT 1. The evidence is at least in equipoise that the Veteran had in-service benzene exposure. 2. The evidence is at least in equipoise that the Veteran’s MDS is related to in-service benzene exposure. CONCLUSION OF LAW The criteria for entitlement to service connection for myelodysplastic syndrome have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from February 1969 to October 1972. He served honorably in the U.S. Air Force, including service in the Republic of Vietnam and the Kingdom of Thailand during the Vietnam era. The Board thanks the Veteran for his service to our country. The Veteran testified before the undersigned at a Board virtual hearing in November 2020. A transcript of the hearing is of record. In December 2020, the Veteran submitted additional evidence, which will be discussed in greater detail below. The Board notes that the appeal has been characterized as a claim to reopen an October 2018 denial which the Agency of Original Jurisdiction reopened and denied in a December 2018 rating decision. However, under 38 C.F.R. § 3.156(b), if new and material evidence is received prior to the expiration of the appeal period, the claim remains pending. In this case, in December 2018, the Veteran submitted additional medical evidence in support of his claim; accordingly, the Veteran’s May 2018 claim, the intent to file for which was received in April 2018, remains a pending claim. Entitlement to service connection for myelodysplastic syndrome is granted. The Veteran contends that his MDS is related to in-service chemical exposures, including benzene. The Board finds that service connection is warranted. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may also 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. To substantiate a claim of service connection, there must be evidence of: (1) a current disability; (2) a disease, injury, or event in service; and (3) a nexus or causal relationship between the claimed disability and the disease, injury, or event in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). In this case, the Veteran served as a Base Fuels Management Officer in the Republic of Vietnam and the Kingdom of Thailand in support of aircraft combat missions. He completed training courses in logistics and petroleum fuels management. In a February 2014 private oncology note, the Veteran reported exposure to petroleum fuels, herbicide agents, and pesticides in the Republic of Vietnam. He reported that he was a retired purchasing agent. In a November 2014 note, he denied a family history of hematologic disease. In an April 2018 private oncology note with the same oncologist, Dr. S., the provider noted that the findings of a March 2018 bone marrow biopsy and aspirate were consistent with sideroblastic anemia representing a low-grade MDS. In an October 2018 letter, Dr. S. concluded that the Veteran’s MDS is at least as likely as not related to in-service herbicide exposure, as there is data “to suggest” that MDS is linked to herbicide agent exposure just as other primary bone disorders have been linked to herbicide agent exposure. In a September 2019 disability benefits questionnaire, Dr. S. again noted exposure to benzene, fuel, and other toxins. Dr. S. indicated that, rather than current treatment for any hematologic or lymphatic condition, including leukemia, the Veteran was being monitored and was still on therapy with other medication. In a Mayo clinic article submitted by the Veteran in October 2019, it was noted that, while some MDSs have no known cause, others are caused by exposure to toxic chemicals such as benzene. According to a CDC factsheet “Facts about Benzene” submitted by the Veteran in October 2019, benzene is a natural part of crude oil and gasoline. With respect to exposure, air around gas stations can contain higher levels of benzene than other areas, and people working in industries that make or use benzene may be exposed to the highest levels of it. The fact sheet also noted that the major effect of benzene from long-term exposure (exposure of a year or more) is on the blood and that benzene causes harmful effects on the bone marrow. According to an American Cancer Society publication “Benzene and Cancer Risk” submitted by the Veteran in March 2020, benzene is a natural part of crude oil and gasoline (and therefore motor vehicle exhaust) and workers in industries that make or use benzene, including gasoline-related industries, can be exposed to benzene; people can also be exposed to benzene in the environment from gasoline fumes. The publication also stated that long-term exposure to benzene mainly harms the bone marrow. In a March 2020 statement, the Veteran relayed being exposed to jet fuel, aviation gas, motor vehicle gas, and diesel. He stated that during his undergraduate pilot training course he had daily exposure to aviation gas and jet fuel fumes and aircraft exhaust fumes, and that as a Base Fuels Management Officer he had daily exposure through fumes and direct skin contact to aviation gas, jet fuel, motor vehicle gas, and diesel. He cited an HHS author manuscript, “Advances in Understanding Benzene Health Effects and Susceptibility,” which noted that the consensus shows that benzene causes MDS, even at relatively low doses. In the November 2020 hearing, the Veteran testified that he served as a fuels manager and officer and that he had all the aviation fuel for reciprocating aircraft, jet fuels, diesel fuels, gasoline motor fuels, and oxygen plants, from bulk storage through distribution, under his control. He testified that he was involved with the fuels all the time, inspecting pipelines and trucks and in distribution on the flight lines. He testified that he was exposed daily to fuels on base, through trucks and pipelines, storage tanks, and filtering equipment. He also testified that he was not aware of a family history of hematologic diseases. In a December 2020 letter, Dr. S. concluded that there is a greater than 50 percent likelihood that the Veteran developed MDS as a result of in-service exposure to benzene and herbicide agents. The Board notes that, while Dr S. associated the MDS in service exposure to benzene and herbicide agents, Dr. S. appears to have based the rationale largely on the Veteran’s exposure to benzene, noting a “significant amount of data and research” indicating an association between MDS and exposure to chemicals including benzene. The Board finds that the evidence is at least in equipoise that the Veteran’s MDS is related to service. The Veteran carries a diagnosis of MDS, fulfilling the first requirement for service connection. Additionally, the Veteran has credibly described fuel exposure during service consistent with the nature of his service. In this respect, he has consistently described daily exposure to aviation, jet, motor, and diesel fuels through pipeline and truck inspections and storage tanks, which is consistent with the places, types, and circumstances of his service as a Base Fuels Management Officer. Additionally, as the evidence of record shows that benzene is a natural part of crude oil and gasoline and increased exposure for people who work in industries that make or use benzene, including gasoline-related industries, the Board finds that the evidence is at least in equipoise that the Veteran had in service benzene exposure. As the first two elements of service connection are thus met, the issue as to whether the Veteran’s MDS is at least as likely as not related to in-service benzene exposure remains. The Board finds that it is. In so finding, the Board notes studies submitted by and cited by the Veteran associating benzene exposure and MDS and assigns probative weight to the opinion of Dr. S., an oncologist with 30 years of experience who has treated the Veteran for anemia and MDS at least since 2014. There is no medical evidence against the Veteran’s claim.   As the evidence is at least in equipoise that the Veteran’s MDS is related to service, service connection for the disorder is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Vashaw, 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.