Citation Nr: 21010706 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 14-35 161 DATE: February 25, 2021 REMANDED The claim for service connection for multiple skin cancers, to include squamous cell and basal cell carcinomata, is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from August 1965 to November 1968. In an October 2012 rating decision, the Regional Office (RO) denied his claim for service connection for multiple skin cancers. The Veteran appealed. In November 2016, the Veteran testified at a Travel Board hearing that, around 1967, he was deployed aboard U.S.S. Kitty Hawk to Subic Bay, Philippines. This is when he went on liberty leave to snorkel at Grande Island where he sustained severe sunburns. A service treatment note dated March 22, 1966, confirms the Veteran’s account, noting that he was admitted to sick bay for treatment lasting approximately five days, due to sustaining multiple 1st and 2d degree sunburns (through no fault of his own) when he was swimming at Grande Island while on liberty leave. In May 2019, the Board remanded the claim to obtain a medical opinion to address whether the Veteran’s skin cancers were the result of his severe sunburn in service. In October 2019, a VA examiner opined that research showed that a one-time only sunburn causes neither squamous cell carcinoma nor basal cell carcinoma of the skin. Rather, most of the research states that it is the cumulative effect from sun exposure which starts during a person’s early childhood years and the cumulative effect of sun exposure normally will manifest after the age of 45 years. Due to these findings it is most likely that the squamous cell and basal cell carcinomas that the Veteran has had in the past are not due to or resulting from the one-time severe sun burn during his military service. Here, the Board observes that the Veteran was awarded Vietnam Service Medal with three bronze service stars, each representing a distinct phase of U.S. military campaigns in Asiatic-Pacific theatre of operation during war service and generally each lasting at least several months. As such, the Veteran likely had been exposed to tropical sun for prolonged periods rather than, as acknowledge by the examiner, the “one-time severe sun burn” sustained while on liberty leave. Further, in a February 2021 Appellate Brief, the Veteran’s representative cited a relevant website for the proposition that: “Even one blistering sunburn in childhood or adolescence more than doubles your chances of developing melanoma later in life.” See (https://www.skincancer.org/risk-factors/sunburn/). Yet the referenced article further states that sunburn is an inflammatory reaction to ultraviolet (UV) radiation damage to the skin’s outermost layers which is a sign of cellular damage to the skin and prolonged unprotected sun exposure. Prolonged sun exposure can cause skin cells to become red, swollen and painful, also known as sunburn. It follows that sunburns themselves are a manifestation of a prolonged sun exposure. Moreover, the article submitted by the representative unequivocally states that “no matter how mild, every burn is a sign of injury to your skin that can result in . . . skin cancer.” Likewise, the research cited by the examiner states that Ultraviolet (UV) radiation is absorbed by DNA and can result in DNA damage, whereas as discussed, supra, sunburn is an inflammatory reaction to ultraviolet (UV) radiation damage to the skin’s outermost layers which is a sign of cellular damage to the skin. If the damage is not repaired, a series of changes can result in malignant transformation. Further epidemiologic studies indicate that cumulative sun exposure (principally UVB radiation) is the most important environmental cause of squamous cell carcinoma. In contrast, intense intermittent sun exposure (e.g., sunburn) is the most important risk factor for basal cell carcinoma. Given these potential conflicts between the medical opinion and the evidence of record, a second opinion should be obtained. Accordingly, the matter is REMANDED for the following action: Obtain an addendum opinion as to the etiology of the Veteran’s squamous and basal cell carcinomata. The examiner is asked the following questions: Is it at least as likely as not (meaning probability of 50 percent or greater) that the Veteran’s multiple skin cancers are etiologically related to his service, to include his sun exposure while serving in Asiatic-Pacific theatre of operations, including his 1st and 2d degree sunburns therein? Why or why not? The examiner is asked to specifically discuss an article at https://www.skincancer.org/risk-factors/sunburn/ and expressly reconcile with any rendered conclusion a statement that “no matter how mild, every burn is a sign of injury to your skin that can result in... skin cancer”. The examiner is further asked to expressly address whether or not the 1st and 2d degree sunburns are indicative of the Ultraviolet (UV) radiation sufficient to be absorbed by DNA to result in DNA damage, and then explain why or why not. (Continued on the next page)   The examiner is asked to address the Veteran’s exposure to sun for the duration of his deployment in the Asiatic-Pacific theatre of operations viewed in light of his skin complexion and explain its significance or insignificance from a medical perspective. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alex Bardin, 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.