Citation Nr: 21024480 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 19-12 197 DATE: April 22, 2021 ORDER Entitlement to service connection for nasopharyngeal cancer is granted. FINDING OF FACT Resolving the benefit of the doubt in his favor, the Veteran’s nasopharyngeal cancer is at least as likely as not related to his military service. CONCLUSION OF LAW The criteria for establishing service connection for nasopharyngeal cancer have been satisfied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1965 to July 1969. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2021. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran contends that he is entitled to service connection for the residuals of a nasopharyngeal carcinoma, to include as due to exposure to pollution and/or chemical agents during his service in Pakistan. Upon review of the evidence of record, the Board finds that the evidence of record is at least in equipoise in this case, and service connection is warranted. The Veteran’s service treatment records demonstrate that he was not diagnosed with a nasopharyngeal carcinoma during his active service. The first evidence of this disability is his late 2015 diagnosis. According to a September 2017 statement provided by the Veteran’s Oncologist, Dr. A.G., submitted with his November 2017 Notice of Disagreement, his initial diagnosis of stage IV nasopharyngeal carcinoma was treated with eight months of aggressive chemotherapy and radiation beginning in February 2016. While his treatment was successful, he continues to have several, significant residuals such as mucositis (inflammation of the upper digestive track), loss of his sense of taste and smell, tinnitus, loss of functioning salivary glands, damage to his palate, hearing loss, and neuropathy. Dr. A.G. also provided the opinion that the Veteran’s cancer is attributed to his military service in Pakistan, noting that the Peshawar district in which the veteran served is the world’s second most polluted city noting an increasing trend of cancer in due to poor air and water quality and poor sanitation. Dr. A.G. stated that, after having treated the Veteran for over a year, she believed there was a direct connection between his diagnosis and the specific environmental conditions in Peshawar at the time of his service, with the region’s high rates of all cancers (including nasopharyngeal carcinoma) being a key factor. Additionally, Dr. A.G. noted that the Veteran was also exposed to toxic and dangerous chemicals as part of his military duties, including arsenic and Trichloroethene (TCE), there was no family history of the Veteran’s cancer that he tested negative for Epstein-Barr (which is linked to nasopharyngeal cancer, and the fact that the Veteran was only a light smoker over three decades ago. Based on Dr. A.G.’s opinion, a VA examination was obtained in February 2019. After review of the evidence, the VA examiner opined that the Veteran’s carcinoma was less likely than not related to in-service exposure and time spent in Pakistan. The VA examiner noted that nasopharyngeal cancer is reported as higher risk for people who were born and grew up in certain Asian countries, including Pakistan, possibly related to genetic factors as well as the native diet. However, the examiner continued, this does not necessarily transfer to American service members who spent relatively limited time in country and, in this Veteran’s case, decades prior to their diagnosis. Instead, the examiner noted that the Veteran’s “advanced age, gender and past smoking history can be considered as risk factors for his cancer.” The examiner also noted that current medical literature has not established an association between arsenic and TCE with nasopharyngeal cancer. In response to the examiner’s opinion and the RO’s continuance of his claim’s denial in a February 2019 Statement of the Case, the Veteran made several additional arguments in both an October 2019 correspondence and during his March 2021 hearing before the undersigned. While the Veteran has not been shown to have any medical expertise, he nonetheless noted several irregularities in the VA examiner’s opinion, including the fact that there was no explanation why the amount of time between his exposure and diagnosis was a factor. The Veteran pointed to similarly situated veterans who served for short periods of time in the Republic of Vietnam, a country they are also not native to, can nonetheless be service-connected for certain cancers after only brief exposure to certain chemical agents. The examiner also, in her opinion that his smoking history was a risk factor for his nasopharyngeal cancer, failed to rationalize the Veteran’s history of having been only a light smoker who quit more than three decades prior. An additional opinion from a separate Oncologist, Dr. A.B. was provided in December 2019, essentially concurring with Dr. A.G.’s opinion, noting the rarity of the Veteran’s cancer in the United States as compared with Pakistan. Having considered the above evidence, the Board cannot find a basis for which one opinion is more probative over the other as to whether the Veteran’s exposure to environmental pollutants and chemicals was at least as likely as not the cause of his rare form of carcinoma. Both medical opinions considered the Veteran’s history and cited to several medical treatises. While the VA examiner was able to review the Veteran’s entire claims file which included his service treatment records, his private physician has been his primary Oncologist since his initial diagnosis. When the evidence is in relative equipoise, i.e., when there is equal evidence both against and in favor of the Veteran's claim, service connection is warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Thus, having afforded him the full benefit of the doubt in this case, the Veteran’s claim of entitlement to service connection for nasopharyngeal cancer is granted. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Scarduzio, 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.