Citation Nr: 21014744 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 15-12 225A DATE: March 15, 2021 ORDER Entitlement to service connection for esophageal cancer is granted. FINDING OF FACT The Veteran’s esophageal cancer is proximately due to his in-service exposure to contaminated drinking water at Camp Lejeune, and service-connected right knee and spine disabilities. CONCLUSION OF LAW The criteria for service connection for esophageal cancer are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Marine Corps from February 1969 to February 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office; this case is in the Board’s legacy appeals system. The Veteran testified at an October 2019 Board hearing before the undersigned; a transcript is associated with the claims file. This matter was most recently before the Board in March 2020, at which time the matter of the Veteran’s entitlement to service connection for esophageal cancer and a low back disability were both remanded. Service connection for degenerative arthritis of the spine was granted by way of an October 2020 rating decision; thus, there remains no case or controversy pending as to this issue. Entitlement to service connection for esophageal cancer. The Veteran contends that he has esophageal cancer (cancer), now status-post esophagectomy, related to his in-service exposure to contaminated water at Camp Lejeune, North Carolina. Alternatively, he contends that his cancer is related to his service-connected disabilities of degenerative arthritis of the right knee and degenerative arthritis of the spine. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). 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). Service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection may be granted on a presumptive basis for certain diseases (listed in 38 C.F.R. § 3.309(f)) associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune if they manifest to a compensable degree at any time after service, even though there is no record of such disease during service. 38 C.F.R. § 3.307(a)(7). A veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987 is presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. Id. The Veteran’s military personnel records show that he was stationed at Camp Lejeune from July 1969 to September 1969 and from January 1970 to February 1971. The Veteran is therefore presumed to have been exposed to the contaminants in the on-base water supply during his active service. While esophageal cancer is not a condition presumptively related to this exposure under 3.309(f), this presumed exposure is still an in-service injury sufficient to support a grant of service connection if the evidence shows a causal connection between the exposure and the Veteran’s cancer. The Board concludes that the Veteran has a current disability of esophageal cancer, status-post esophagectomy, that is related to a combination of his in-service exposure to contaminated water and his service-connected arthritis of the right knee and spine. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), 3.310. Post service treatment records show the Veteran complained of food sticking in his throat in December 2012 and was diagnosed with invasive adenocarcinoma of the esophagus in January 2013. He underwent treatment including a June 2013 esophagectomy and has testified to his continuing symptoms as a result of that surgery. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes VA medical opinions of November 2014 and July 2019 as well as a VA endocrinology exam of October 2020. The evidence in favor of the claim includes private medical opinions of June 2018, October 2019, and July 2020. In November 2014, Dr. T.G. opined that the Veteran’s cancer was less likely than not related to his in-service exposure to contaminants in the water at Camp Lejeune. His rationale included the Veteran’s relatively lower cumulative exposure to contaminated water, which he calculated as 346 days, as compared to 18 months for Marines who participated in medical studies of the effects of this exposure, as well as the Veteran’s known risk factors such as his male gender, age greater than 55 at diagnosis, body mass index (BMI) of 28 before diagnosis, Caucasian ethnicity, GERD, and history of smoking. Dr. T.G. cited studies showing that esophageal adenocarcinoma is “largely a disease of Caucasians and males,” that smoking increased risk while smoking cessation did not reduce it, and that people with a BMI greater than 25 were at increased risk, possibly related to their increased risk for GERD, another known risk factor. In June 2018, Dr. M.L. opined that the Veteran’s cancer was at least as likely as not caused by his in-service exposure to contaminants in the water at Camp Lejeune. He cited a study showing evidence for consistent positive associations between contaminants at Camp Lejeune and esophageal cancer. In response to Dr. T.G.’s argument that lower cumulative exposure weighed against service connection, Dr. M.L. cited a study showing that those with low cumulative exposure developed esophageal cancer at higher rates than those with higher cumulative exposure. Statistical analysis of the same study also noted that confounding variables, such as smoking, had minimal effect on the strength of association with esophageal cancer. Dr. T.G. noted that these studies, along with the lack of other known risk factors such as family history of gastrointestinal issues, or heavy drinking or smoking, made it at least as likely as not that in-service exposures caused the Veteran’s cancer. In July 2019, Dr. M.M. concurred with Dr. T.G.’s November 2014 negative opinion, providing a similar rationale but also specifically responding to Dr. M.L.’s June 2018 opinion. Dr. M.M. criticized Dr. M.L.’s opinion for failing to discuss the Veteran’s known risk factors including age, gender, history of GERD, and history of heavy smoking and drinking. He also disagreed with Dr. M.L. as to the strength of the medical evidence showing any connection between the contaminants in the water at Camp Lejeune and esophageal adenocarcinoma. In October 2019, Dr. S.B. opined that the Veteran’s cancer was at least as likely as not caused by a combination of his in-service exposure to contaminants in the water at Camp Lejeune and his service-connected disabilities of arthritis of the right knee and spine. He disagreed with Dr. T.G.’s assertion that a lower cumulative exposure level was less likely to result in developing cancer, as there have been no studies showing such a difference in effect based on dosage/exposure levels. He also cited studies not performed on Marines, showing significant nexus from the same type of contaminant to esophageal cancer. These studies also showed no change when accounting for confounding variables of smoking and obesity. Addressing Dr. T.G.’s opinion that non-exposure risk factors were more likely to have caused the Veteran’s cancer, Dr. S.B. noted that there have been no risk stratifying studies comparing the propensity of known risk factors to cause the disease. Regarding the Veteran’s obesity at time of diagnosis, with a BMI of 28, Dr. S.B. agreed that it likely contributed to the Veteran’s cancer. However, citing studies showing that back pain leads to a sedentary lifestyle and obesity, he opined that the Veteran’s service-connected arthritis of the right knee and spine led to a sedentary lifestyle and his resulting weight gain. He therefore opined that this factor also weighed in favor of finding that the Veteran’s cancer was related to service or service-connected disabilities. Dr. S.B. acknowledged that the cause of the Veteran’s cancer was likely multifactorial, and acknowledged the Veteran’s known risk factors including age, ethnicity, obesity, GERD, and history of smoking and drinking. He then opined that in the absence of stratifying studies showing which risk factors had a higher propensity for causing the disease, it was at least as likely as not that the Veteran’s in-service exposure and obesity were the causes of the Veteran’s cancer. In July 2020, Dr. S.B. submitted an addendum opinion providing some clarification of his previously stated rationale with additional citations to support his reasoning. In October 2020, VA provided an examination for endocrinological conditions which was intended to determine whether or not the Veteran’s obesity was related to his service-connected disabilities. At the time of the examination, the Veteran was not obese and denied ever being obese or suffering from any conditions as the result of obesity. The examiner therefore opined that the Veteran did not have obesity secondary to his service-connected disabilities. The examiner did not discuss the Veteran’s medical records showing a BMI of 28 in 2012. The Board assigns little probative value to the VA examination and opinion of October 2020 because the examiner failed to discuss the objective evidence of the Veteran’s recorded BMI of 28 in 2012, before he was diagnosed with cancer. Similarly, the Board assigned little probative weight to Dr. M.L.’s opinion of July 2018 because Dr. M.L. failed to address several of the Veteran’s known risk factors and was mistaken in stating that the Veteran did not have a history of smoking. The Board finds that the VA opinions of November 2014 and July 2019, as well as the combined private opinions of Dr. S.B., are well reasoned and supported by relevant medical literature. The authors agree that there is some evidence of a connection between exposure to the type of chemicals in the contaminated water at Camp Lejeune and developing esophageal adenocarcinoma, although they disagree as to the strength of this association. They also agree that obesity is a risk factor for developing this cancer, although only Dr. S.B. noted the relationship between the Veteran’s other service-connected disabilities and his obesity. The Board is ultimately persuaded by Dr. S.B.’s observation that in the absence of stratifying studies showing that any risk factor is more likely than the others to cause esophageal carcinoma, there is no reason to say that any of the Veteran’s non-service related risk factors were more likely than his obesity or in-service chemical exposures to have caused his cancer. (Continued on the next page)   The Board therefore finds the evidence to at least be in equipoise as to whether the Veteran’s esophageal cancer is related to his in-service exposure to contaminated water at Camp Lejeune or to his service-connected right knee and spine disabilities. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for esophageal cancer is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. M. C. WILSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Zimmerman 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.