Citation Nr: 21026782 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-58 757A DATE: May 4, 2021 ORDER Entitlement to service connection for left breast cancer, to include as due to exposure to contaminated water at Camp Lejeune, is denied. FINDING OF FACT Left breast cancer did not have its onset during active service or within one year of service discharge and is not otherwise due to active service, to include as due to exposure to contaminated water at Camp Lejeune. CONCLUSION OF LAW The criteria for service connection for left breast cancer, to include as due to exposure to contaminated water at Camp Lejeune, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from June 1972 to June 1976, including service at Camp LeJeune from September 1975 to June1976. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a September 2020 virtual hearing and a transcript has been associated with the claims file. This matter was previously remanded by the Board in December 2020 in order to obtain an addendum opinion by a qualified subject matter expert. As the requested development has been completed, the matter is properly returned to the Board for adjudication. Additionally, the Veteran's submission of a January 2021 private addendum opinion is properly considered by the Board in the first instance as his VA Form 9 substantive appeal was filed on or after February 2, 2013. 38 U.S.C. § 7105(e). As noted in the December 2020 remand, the Board again acknowledges that the Veteran has properly initiated an appeal regarding his claim of entitlement to service connection for prostate cancer, to include as due to exposure to contaminated water at Camp Lejeune, based upon his timely submission of a June 2019 notice of disagreement (NOD). However, the record does not currently document that the agency of original jurisdiction (AOJ) has yet issued a related statement of the case (SOC) or that the Veteran has properly perfected an appeal to the Board; therefore, this matter is not currently before the Board and it will not be addressed herein. Entitlement to service connection for left breast cancer, to include as due to exposure to contaminated water at Camp Lejeune The Veteran claims that his left breast cancer is the result of his active service, to include as due to his presumed exposure to contaminated water at Camp Lejeune. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. To establish a right to compensation for a 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. For certain chronic disorders, including malignant tumors, service connection may be granted on a presumptive basis if the disease is manifested to a compensable degree within one year following service discharge. Service connection may also be granted on a presumptive basis for certain specified diseases as due to presumed exposure to the contaminants in the water supply at Camp Lejeune (including the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene, and vinyl chloride) provided the disease manifests to a compensable degree at any time after service in a Veteran who had no less than 30days (consecutive or nonconsecutive) of active service at Camp Lejeune during the period beginning on August 1, 1953 and ending on December 31, 1987. The Veteran's service personnel records document that he had the requisite active service at Camp Lejeune from September 1975 to June 1976; therefore, he is presumed to have been exposed to the contaminated water supply at Camp Lejeune. However, following a review of the evidence of record, and as discussed further below, the Board finds that the preponderance of the evidence weighs against the Veteran's claim. The reasons for this decision follow. As to the first element of a service-connection claim, a current disability, the Board notes that post-service private treatment records show that the Veteran was diagnosed with breast cancer by biopsy in July 2010. As such, the first element of the Veteran's service-connection claim is met. As to the second element of an in-service disease or injury, the Board notes that service treatment records do not document complaints, treatment, or diagnosis of left breast cancer during active service. A January 1972 pre-induction Report of Medical Examination documents normal clinical evaluations and the Veteran denied a history of cancer within a concurrent Report of Medical History. A June 1972 Report of Medical Examination similarly documents normal clinical evaluations. Finally, a May 1976 Report of Medical Examination prior to discharge again documents normal clinical evaluations, with no left breast cancer defect or diagnosis noted. Given the above, the Board finds that the evidence of record does not document an in-service incurrence of left breast cancer. Nevertheless, as the Veteran's stated theory of entitlement asserts that his left breast cancer is related to presumed exposure to contaminated water at Camp Lejeune, such exposure is sufficient to meet the in-service element of the Veteran's claim. Notably, however, there is no competent evidence that left breast cancer first manifested during active service or within one year of service discharge to warrant presumptive service connection for malignant tumors as a chronic disease. Additionally, the Board is mindful that left breast cancer is not a disease that VA has determined to be presumptively associated with exposure to contaminated water at Camp Lejeune; therefore, service connection for left breast cancer cannot be granted on a presumptive basis due to such exposure. Nevertheless, the Veteran may still provide evidence that his left breast cancer is directly due to exposure to contaminated water at Camp Lejeune. However, as discussed below, the Board finds that the most probative evidence of record weighs against a finding that the Veteran's left breast cancer is related to his active service, to include as a result of exposure to contaminated water at Camp Lejeune. Private treatment records document the Veteran's diagnosis of left breast cancer following a biopsy in July 2010. Thereafter, he underwent left breast mastectomy in August 2010. That same month, the Veteran discussed breast cancer gene testing (BRCA) for him and his family. In October 2010, a private physician, James A. Stewart, stated that the Veteran had "a mutation of undetermined significance" and it was discussed that since his mother also had breast cancer, she would be the obvious person to test next. Dr. Stewart noted that if she had a similar mutation, then the uncertain significance category likely goes away as the mutation probably has deleterious significance. In December 2010, Dr. Stewart noted that the Veteran and his mother had both been tested and had the same mutation that was designated as a "mutation of uncertain significance." Dr. Stewart stated that the testing company did not have enough families with this mutation to make a firm statement about whether or not it is clearly a deleterious mutation. Upon VA examination in July 2014, a VA examiner opined that the Veteran's left breast cancer was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner acknowledged that the Veteran was diagnosed with breast cancer by biopsy in July 2010 and that he had been stationed at Camp LeJeune from September 1975 to June1976. However, the examiner stated that medical literature, including NIH, ATSDR, and NRC showed additional known risk factors for breast cancer, including his mother's family history of breast cancer and a longstanding history of morbid obesity, outweighed any limited or suggestive evidence of association with contaminated water at Camp Lejeune. In August 2019, a private physician, Dr. Christopher King, opined that the Veteran's diagnosis of breast cancer is at least as likely as not caused by his service at Camp Lejeune and exposure to the known carcinogens there. In support of his opinion, Dr. King stated that the great majority of breast cancers (>90 percent) are considered the consequence of exposure to environmental carcinogens and the most recent (2018) review of environmental carcinogens and breast cancer implicates organic solvents such as PCE and TCE as causative. Additionally, he stated that epidemiologic studies have shown an increased risk of male breast cancer for those stationed at Camp Lejeune during the era of water contamination as compared to other camps or with the general population, with the solvent PCE having been specifically shown to increase breast cancer diagnoses by 30-100 percent among those exposed. Dr. King noted that the Veteran also has some personal risk factors for breast cancer, including race, family history, and obesity, but he stated that in the context of conceded exposure to carcinogens at Camp Lejeune, and with multiple medical and scientific studies associating that with increased risk for breast cancer, one has to weigh the competing personal risk factors versus the evidence linking those carcinogens with these cancers. Additionally, he stated that since there is no scientific way to quantify these competing risks, to offer a conclusion one way or the other amounts to nothing other than a biased opinion without evidence. A September 2019 submission by the Veteran's attorney noted that an evaluation of contaminated drinking water and male breast cancer at Camp Lejeune found suggested possible associations between male breast cancer and being stationed at Camp Lejeune and cumulative exposure to PCE, DCE, and vinyl chloride. TCE, ICE, DCE and vinyl chloride cumulative exposures showed possible associations with earlier age at onset of male breast cancer. However, the study was limited by small numbers of cases in high exposure categories. At the September 2020 Board hearing, the Veteran testified that the only doctor who told him that his breast cancer was due to his time at Camp Lejeune was Dr. King, and that all of his other physicians had either retired or they would not provide an opinion. The Veteran's attorney asserted that Dr. King's nexus opinion was highly probative and that conversely, the July 2014 VA opinion was inadequate given its focus on the Veteran's personal risk factors for developing breast cancer of obesity and family history. The attorney stated that after the Veteran was biopsied for breast cancer, he and his mother underwent genetic testing to see if they had the same mutation, and treatment records from Baystate Medical Center in June 2011 show that they do, but a doctor stated that the significance of this mutation in terms of causing cancer is uncertain. Thus, the attorney asserted that the VA examiner's reliance on positive family history as conclusive evidence that contributed to the breast cancer is inadequate. In terms of obesity, the attorney stated that Dr. King pointed out that the studies linking obesity to breast cancer were performed in women and not men, which the examiner stated undermined the VA examination in terms of its reliance on obesity as a risk factor. As noted above, this matter was previously remanded by the Board in December 2020 for additional development. Thereafter, in January 2021, Dr. King submitted an additional private addendum opinion which noted that his original opinion remained unchanged. To the extent that the December 2020 Board remand pointed out that he did not mention that the familial history of breast cancer extended beyond his mother to his maternal grandmother, Dr. King stated that this point is irrelevant. He noted that he had already mentioned the Veteran's family history of breast cancer in his mother, and the risk associated with family history is predominantly one of first-degree relatives (based upon reference to three medical articles: 1. American Society for Clinical Oncology, Breast Cancer in Men: Risk Factors; 2. National Cancer Institute, Male Breast Cancer; and 3. Mayo Clinic, Male Breast Cancer). Dr. King stated that the Veteran's grandmother's history of breast cancer adds nothing to the family history factor, which was already taken into account in his prior opinion. Additionally, he stated that family history as a risk factor is primarily based on inherited mutations, specifically the BRCA1 and BRCA2 mutation. Dr. King noted the Veteran was tested for those mutations and was negative, essentially negating family risk as a relevant factor in his case. Thus, Dr. King maintained his conclusion in its entirety and unchanged, that the Veteran's breast cancer was at least as likely as not caused by his exposure to known carcinogens at Camp Lejeune as they relate to breast cancer, namely TCE and PCE. Later in January 2021, a VA examiner reviewed the claims file and opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner stated that the Veteran has several strong and well-recognized risk factors for breast cancer, including an undisputed positive family history (increasing risk 2-5 times), a BRCA mutation (the strongest risk factor, increasing risk 10-100 times over unaffected men), race (another risk factor with a strong association), obesity which was "present for many years" (a well-accepted risk factor in males, with known biochemical effects leading to elevated estrogen levels which stimulate ductal tissue), and diabetes (also a recognized risk factor with known physiologic effects). The examiner further noted that the Veteran's exposure to the water at Camp LeJeune was relatively brief at 9 months, and the literature is suggestive or inconsistent regarding an association of TCE and PCE but generally suggests that longer exposures are needed (over 5-10 years). On balance, the examiner concluded that the impact of personal and inherited risk factors greatly exceeds any potential effect of the relatively short exposure [at Camp Lejeune]. Additionally, the examiner included a thorough and detailed discussion of the Veteran's history, the risk factors for breast cancer, and the studies regarding exposure to contaminated water at Camp Lejeune, including a review of relevant scientific articles and medical studies on these topics. Following an in-depth discussion of this material, the examiner again concluded that the likely cause of the Veteran's breast cancer is the strong positive family history, which risk is further increased by the detected BRCA mutation, followed by ethnicity, obesity, and diabetes, which likely factors were present for many years. Given this, the examiner stated that the impact of the Camp Lejeune exposure would be minimal. In February 2021, the same VA examiner offered an addendum opinion after a review of the positive private opinion by Dr. King. The examiner noted that Dr. King opined that the Veteran's breast cancer was as likely as not caused by service at Camp LeJeune, and he stated that the great majority of breast cancers are considered the consequence of exposure to environmental chemicals, quoted as over 90 percent. The examiner noted that this statistic (90 percent) was not referenced, but that it appeared to be based on a 2019 study by Lewandowska, although that cannot be confirmed. The examiner's January 2021 opinion included a detailed discussion of Lewandowska's conclusion, which "presents a broad general overview of the literature using all-encompassing definitions of environmental factors," including physical factors (like electromagnetic fields, ionizing radon, and ultraviolet radiation), chemical factors (like tobacco smoking and alcohol use), and biological factors (including diet, physical inactivity, and infections), while specific links to breast cancer were cited for electromagnetic fields, ionizing radiation, smoking, alcohol use, overweight and obesity, reduced physical activity, and mycotoxins. Notably, chlorinated solvents were not discussed or related to breast cancer. As such, the examiner opined that the conclusion reached by Dr. King is not supported in the Lewandowska review. The examiner noted that Dr. King also cited Rodgers (2017) as it "implicates organic solvents such as PCE and TCE as causative." The examiner's January 2021 opinion included a detailed discussion of that review, which notably focused primarily on women, discussed various solvents, and was not limited to the solvents at Camp LeJeune. It reported both positive and negative studies, citing many years of exposure in the positive studies. Overall, the work was suggestive of a possible association, but not sufficient to establish a causal relationship. It concluded that evidence of an association is accumulating for solvents in general. The examiner acknowledged that it is possible that a causal relationship could be established in the future if continued research supports that. Additionally, the examiner noted that Dr. King stated that epidemiological studies have shown an increased risk of male breast cancer for those exposed to contaminated water at Camp LeJeune, citing a 30 to 100 percent increase among those exposed; however, the examiner stated that such an assertion is not supported by the studies discussed in the detailed January 2021 opinion, including two Bove 2014 mortality studies, promulgated by ATSDR in 2018, which report results for female breast cancer only. Ruckart (2015) examined male breast cancer, as discussed above. Risk-adjusted rates were used to formulate the conclusions. The examiner pointed out that Dr. King appears to have cited the unadjusted rates from one table in his assertion; however, in his clinical review, Dr. King overlooked the history of breast cancer in the Veteran's maternal grandmother and the BRCA gene mutation on genetic testing. The examiner stated that the fact that it was not the more common BRCA1 or BRCA2 mutation does not mean it has no relevance. Rather, the examiner reiterated the opinion that, on balance, the likely cause of the Veteran's breast cancer is the strong positive family history, which was further increased by the detected BRCA mutation, followed by ethnicity, obesity, and diabetes, which factors were present for many years, while the impact of the Camp LeJeune exposure would be minimal. After consideration of the conflicting nexus opinions of record discussed above, the Board affords greater probative value to the January 2021 and February 2021 VA examiner's opinions, which are well-supported by a probative rationale based upon consideration of the Veteran's specific theory of entitlement and the private nexus opinions supporting his claim, as well as a detailed discussion of the conflicting private nexus opinion and related medical literature and scientific expertise. The VA examiner's opinion sufficiently refuted findings within Dr. King's opinions to lessen the probative value of Dr. King's opinions, including discussing the medical literature Dr. King interpreted to provide a positive nexus opinion. To the extent that the lay statements of the Veteran assert that his left breast cancer is related to his active service, to include as due exposure to contaminated water at Camp Lejeune, the Board finds that the Veteran is not competent to provide a nexus opinion to link breast cancer to the Veteran's active service, including exposure to contaminated water, as medical expertise is required. In this regard, the question of causation involves a medical and scientific subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the lay opinions of the Veteran are nonprobative evidence. Given the above evidence, the Board finds that the preponderance of the evidence weighs against the Veteran's claim of entitlement to service connection for left breast cancer, to include as a result of exposure to contaminated water at Camp Lejeune. As the preponderance of the evidence is against the Veteran's claim, there is no reasonable doubt to be resolved, and the claim is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chad Johnson, 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.