Citation Nr: 21023795 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 15-36 708 DATE: April 21, 2021 ORDER Entitlement to service connection for melanoma, basal cell carcinoma, and squamous cell carcinoma (skin cancer) residuals is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran’s skin cancer residuals are related to his in-service sunlight exposure. CONCLUSION OF LAW With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for skin cancer residuals are met. 38 U.S.C. §§ 1110, 1131, 1154 (a), 5107; 38 C.F.R. §§ 3.102, 3.303.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from November 1969 to March 1977, to include service in the Republic of Vietnam. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in September 2012, December 2013, and March 2015 by a Department of Veterans Affairs (VA) Regional Office (RO or AOJ). In April 2017, the Veteran testified at a Travel Board Hearing before the undersigned Veterans Law Judge. The transcript of that hearing is of record. This matter was previously remanded in August 2018, December 2019, and September 2020, for further development. It has now returned to the Board for adjudication. Entitlement to Service Connection for Skin Cancer Residuals Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Generally, 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303 (d).   As an initial matter, the Board acknowledges that the Veteran is service-connected for dermatophytosis also claimed as skin condition. See September 2012 rating decision. However, during the pendency of the appeal, the Veteran’s non-cancerous skin disability has also been diagnosed alternatively as dermatophytosis, dermatitis, and/or psoriasis. See October 2013, March 2014, October 2020, and November 2020 VA examination reports. The Board will consider, as did the RO, the dermatitis and/or psoriasis as part of the service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the effects of the service-connected condition from any nonservice-connected condition, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant’s favor and that such manifestations be attributed to the service-connected disability). Turning to the Veteran’s claim for service connection for skin cancer residuals, the Veteran has been diagnosed, and treated for, melanoma and basal and squamous cell carcinoma. See October 2013, March 2014, January 2019, and January 2020 VA examination reports. A current disability has been demonstrated. As to the in-service injury or disease element, the Veteran asserts that he had extensive exposure to sunlight as well as to herbicide agents (such as Agent Orange), fuel, battery acids, and/or organic solvents during service in the Republic of Vietnam in the course of his military duties. He states his duties required him to be in and around Naval helicopters and avionics with repeated exposure to environmental factors. See April 2017 hearing transcript. The Veteran’s service records show that his military occupational specialty (MOS) was a Radio Operator. Military personnel records also show that while serving in the Republic of Vietnam, he was assigned to the Fleet Air Support Unit. Based on the Veteran’s credible testimony regarding repeated exposure to sunlight during service in the Republic of Vietnam, combined with a review of the Veteran’s military personnel records verifying his duty station while serving in the Republic of Vietnam, the Board concedes the Veteran had significant exposure to sunlight. See 38 U.S.C. § 1154 (a). The in-service injury requirement has been met. As such, the crux of this case centers on whether the Veteran’s skin cancer residuals are etiologically related to his in-service sunlight exposure. In a December 2020 private medical opinion, the Veteran’s treating dermatologist, Dr. D.A., indicated that “likely there is a correlation between [the Veteran’s] sun exposure during his military service and the onset of multiple cancers.” Her opinion was based on treatment of the Veteran since 2017, and being aware of his “long history of these conditions.” While such is not accompanied by a full rationale, it provides evidence in favor of the claim. Evidence against the Veteran’s claim includes an October 2013 VA medical opinion finding the Veteran’s skin cancer residuals were less likely than not related to his military service. The examiner stated the Veteran’s skin cancer residuals were most likely related to sun exposure from outdoor activities after military service. A January 2019 VA examiner indicated that it would be mere speculation to say that sun exposure in service caused the Veteran’s skin cancer residuals which did not develop until 22 years after service. A January 2020 VA examiner determined there is no way to quantify the amount of sun exposure required or if indeed the Veteran had significantly more exposure while in Vietnam than all other years of his life. Taken another way, the examiner seems to acknowledge that the Veteran’s in-service sunlight exposure may have played a role in his development of skin cancer or at that it could at least not be definitively excluded. The examiner added that other risk factors for the development of melanoma are fair skin and a high level of nevi burden. It was noted that the Veteran does have fair skin and noted to have multiple nevi. In that regard, the October 2013, January 2019, and January 2020 VA examiners did not consider the Veteran’s service in the Republic of Vietnam and his report of repeated exposure to environmental factors, which the Board concedes included exposure to sunlight. The examiners also failed to elicit relevant information from the Veteran in order to determine his post-service sun exposure. In this regard, the record indicates the Veteran’s civilian occupations were mostly office jobs,   including marketing, franchise broker/consultant, human resources assistant, certified peer support specialist, claims examiner, and operator/counselor/medical support assistant. See April 2014 VR&E record and July 2020 statement. The suggestion has been made, or at least intimated, that the only significant and prolonged exposure to the sun occurred during the Veteran’s active service. A March 2014 VA examiner opined the etiology of melanoma remains unknown, though much data links sunlight to melanoma. The examiner added that some clarification should emerge from the potential isolation of genes that carry susceptibility to melanoma in families prone to the disease. A November 2020 VA examiner opined that melanoma and basal cell carcinoma are known to be related to chronic sun exposure over many years. The examiner added that melanoma as well as other forms of skin carcinoma have significant familial risk and that one subtype of melanoma is not necessarily related to sun exposure and has a high genetic factor. However, the March 2014 and November 2020 VA examiners did not address the Veteran’s treatment records which indicate the Veteran has no family history of melanoma. See February 2014 private treatment record and April 2016 VA treatment record. The Board finds that the December 2020 private opinion regarding a relationship between sunlight exposure and skin cancer supports that the Veteran’s skin cancer residuals is related to his in-service sunlight exposure. The December 2020 private opinion is probative as it was provided by the Veteran’s treating physician who is a specialist in dermatology and familiar with his medical history. Additionally, the Board finds that the Veteran’s skin cancer residuals were not conclusively disassociated with his service by the VA examiners. Indeed, as discussed, some of those examiners have acknowledged that sun exposure was a likely factor in the Veteran’s development of these skin cancers.   The evidence is, therefore, at least evenly balanced as to whether the Veteran’s skin cancer residuals is related to his in-service sunlight exposure, and service connection for melanoma, basal cell carcinoma, and squamous cell carcinoma (skin cancer) residuals is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.