Citation Nr: 21025181 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-33 381A DATE: April 27, 2021 REMANDED Entitlement to service connection for squamous cell carcinoma is remanded. Entitlement to service connection for basal cell carcinoma with scarring is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1966 to August 1969, to include service in the Republic of Vietnam. The Veteran was awarded the Purple Heart Medal for his honorable service. The Veteran died in November 2019. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision issued by a Regional Office (RO) of the United States Department of Veterans Affairs (VA). In November 2020, the Veteran’s surviving spouse was substituted as the appellant. As to the matters on appeal, the late Veteran and the appellant presented sworn testimony before the undersigned Veterans Law Judge at an October 2018 Board hearing. In July 2019, the Board issued a decision denying the claims, as the most probative evidence established that the Veteran’s claimed squamous cell carcinoma and basal cell carcinoma with scarring was not shown to be etiologically or presumptively related to an in-service event, injury or disease, to include in-service exposure to herbicide agents. In April 2020, the Board vacated the July 2019 decision because relevant evidence had been received by VA prior to promulgation of the July 2019 Board decision, but it had not yet been associated with the electronic claims file at the time the decision was issued. To protect the due process rights of the appellant and to ensure fairness in the adjudication of the claims, the July 2019 Board decision was vacated. The claims have now returned for appellate consideration. The evidence missing from the electronic claims file at the time of the July 2019 Board decision included two favorable nexus opinions, each linking the Veteran’s squamous cell and basal cell carcinomas to the immunosuppressive treatment prescribed for the Veteran’s service-connected Crohn’s disease, and a medical journal article entitled, “Azathioprine linked to increased risk of [squamous cell carcinoma] in transplant recipients.” In an April 2019 letter, Dr. GW noted the Veteran’s long history of service-connected Crohn’s disease with subsequent long-term immunosuppressive treatment, and stated, “[t]he setting of Crohn’s disease which has required this immunosuppression I feel has led to the development of squamous cell and basal cell carcinomas. In my opinion, [the Veteran’s] military service has led to these numerous basal and squamous cell carcinomas. An August 2019 medical opinion by Dr. G.W. was cumulative of the April 2019 statement. In a June 2019 letter, Dr. RJS noted the Veteran’s history of service-connected Crohn’s disease, his subsequent development of colon adenocarcinoma, and his long-term immunosuppressive treatment. Dr. RJS stated, “[a]s detailed in surveillance studies, long term immunosuppression leads to increased incidence of non-melanoma skin cancer. In my opinion, [the Veteran’s] military service, leading to his service[-]connected Crohn’s disease and it’s management with immune suppressive medication has more likely than not led to his multiple non-melanoma (basal cell and squamous cell) carcinomas.” Regrettably, neither of these favorable medical opinions are sufficiently probative to resolve the Veteran’s appeal. The Board recognizes that the Court of Appeals for Veterans Claims (Court) has held that most of the probative value of a medical opinion comes from its reasoning and the Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007), the Court held that “a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor’s opinion.” The April 2019 and August 2019 private medical opinions by Dr. GW contain only a conclusion, without any rationale, rendering them void of probative value. The June 2019 private medical opinion by Dr. RJS went a step further, noting that scientific research indicates long-term immunosuppression has been linked to an increased incidence of non-melanoma skin cancer, but did not explain the underlying pathophysiological process or which evidence in the claims file demonstrated that long-term immunosuppressive therapy led to the development of basal cell and squamous cell carcinoma in the Veteran’s particular case. A statistical correlation, manifested by “an increased incidence,” is not causation, and 38 C.F.R. § 3.310(a) requires proximate causation before service connection can be granted as secondary to a service-connected disability. Regarding the medical journal article that was submitted, medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). In this regard, the Board notes that treatise evidence must “not simply provide speculative generic statements not relevant to the Veteran’s claim.” Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, “standing alone,” must discuss “generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Id. Here, the article that was submitted summarized several studies and concluded that “[i]mmunosuppressive treatment with azathioprine may be associated with an increased risk of squamous cell carcinoma in organ transplant recipients, but does not appear to increase the risk of basal cell carcinoma…overall.” While the Veteran’s Crohn’s disease has been treated with azathioprine, the Board finds this medical article to be insufficient to resolve the appeal, as its conclusion regarding the increased risk of squamous cell carcinoma was limited to organ transplant recipients—which is not the Veteran’s case—and the article specifically stated that the use of azathioprine “does not appear to increase the risk of basal cell carcinoma.” Given the evidentiary issues identified above, the Board finds that remand is appropriate for a VA medical opinion that fully addresses and explains whether the Veteran’s squamous cell and basal cell carcinomas are proximately due to, the result of, or aggravated by the Veteran’s service-connected Crohn’s disease and the long-term use of immunosuppressive therapy. See 38 C.F.R. § 3.310. [Continued on Next Page]   The matters are REMANDED for the following action: Obtain a VA medical opinion from an appropriate VA examiner regarding the etiology of the Veteran’s squamous cell and basal cell carcinomas. Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries: 1. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s squamous cell and basal cell carcinomas were proximately due to or the result of the long-term immunosuppressive therapy used to treat the Veteran’s service-connected Crohn’s disease? 2. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s squamous cell and basal cell carcinomas underwent any incremental increase in disability, regardless of its permanence, due to the long-term immunosuppressive therapy used to treat the Veteran’s service-connected Crohn’s disease? See Ward v. Wilkie, 31 Vet. App. 233 (2019). The term “incremental increase in disability” means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any “incremental increase in disability” need not be permanent. The VA examiner is requested to consider and address the April 2019, August 2019, and June 2019 private medical opinions, as well as the medical article discussing azathioprine and the increased risk of developing non-melanoma skin carcinomas. The VA examiner must provide a complete rationale for any opinion expressed that is based on the examiner’s clinical experience and medical expertise; established medical principles; and citation to the evidence of record, as appropriate. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Galante 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.