Citation Nr: 21027557 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 15-21 876 DATE: May 6, 2021 ORDER Entitlement to Dependency and Indemnity Compensation (DIC) based on service connection for cause of death is denied. FINDING OF FACT The preponderance of the evidence establishes that neither service-connected PTSD nor any other service-connected disorder was a principal or contributory cause of the Veteran's death, nor did such disabilities hasten his death. CONCLUSION OF LAW The criteria for entitlement to DIC based on service connection for cause of death have not been met. 38 U.S.C. §§ 101(16), 1101, 1110, 1112, 1113, 1131, 1137, 1310, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.1(k), 3.5(a), 3.102, 3.159, 3.303, 3.312 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from May 1987 to September 1987 and from September 1988 to May 1992. He died in January 2014, and the Appellant is the Veteran's surviving spouse. This matter was initially before the Board where it was remanded for additional development. Specifically, a medical opinion was requested to determine whether the Veteran's service-connected PTSD caused or aggravated his alcohol use and contributed to the cause of his death. The Board finds that this opinion adequately addressed all questions posed the Board and is supported by reference to specific facts in this case. Entitlement to DIC based on service connection for cause of death DIC benefits are payable to the surviving spouse of a Veteran if the Veteran died from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. § 3.5. 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"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A Veteran's death will be considered as being due to a service-connected disability when the evidence establishes that the service-connected disability was either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a). The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one that is not related to the principal cause. In order for a service-connected disability to be determined as a contributory cause of a Veteran's death, it must be shown that it contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran was service-connected PTSD with depressive disorder not otherwise specified (NOS), residuals of closed head injury with dementia, degenerative disc disease of the lumbar spine, radiculopathy of the right and left lower extremities, and tinnitus. In this case, the Veteran died in January 2014. According to his death certificate, the Veteran's causes of death were subacute liver failure that had a one-week interval between his onset and death, and metastatic pancreatic adenocarcinoma (pancreatic cancer) that had a one-year interval between his onset and death. At the time of the Veteran's death, he was service-connected for PTSD (among other disabilities). The Veteran, however, was not service-connected for any pancreatic or liver disability. The Appellant primarily contends that the Veteran's service-connected PTSD caused and/or aggravated his alcoholism and substance abuse, which subsequently caused his liver failure and pancreatic cancer. In support of her argument, the Appellant submitted a private medical opinion, dated December 2015. The registered nurse, J.P., opined as follows: I reviewed information provided to me by the veteran's widow and her attorney. Based on this information, I offer the following related to the veteran's claim(s). The question is whether the veteran died from a service-connected condition. Based on the information provided to me I think that the veteran's alcoholism and drug abuse arising from his PTSD lead to the pancreas and liver problems that caused his death. I believe that these disabilities may be related to events while he was in service. Based on information provided, it is possible that the above described disabilities were caused during the veteran's time in service. I suggest that the matter undergo a more certain evaluation to ascertain causation. On remand, the Appellant was afforded a VA examination in March 2020 to determine whether the Veteran's service-connected PTSD and alcohol use contributed to the cause of his death. The examiner detailed the Veteran's lengthy medical history as well as the Appellant's contentions. He opined that it was less likely than not that the Veteran's pancreatic cancer, which caused his subacute liver failure, had its origin in alcohol consumption, to include any consumption attributed to his service-connected PTSD. The examiner reasoned that "the role of alcohol in pancreatic cancer is minimal - apparently the same magnitude as coffee consumption." The likelihood of alcohol having caused pancreatic cancer is smaller than 6.2%. Additionally, the Veteran's medical records did not contain any clinician attributing alcohol use to his service-connected PTSD. The examiner stated that the Mayo Clinic lists pancreatic inflammation as a risk for pancreatic cancer and that "alcoholic pancreatitis might be the cause of the cancer. However, there is no evidence in medical record of [the] [V]eteran having had pancreatitis." In reviewing the Veteran's liver enzymes, most of the liver enzyme abnormalities most closely associated with alcohol abuse were not seen prior to his diagnosis of pancreatic cancer. Lastly, the examiner determined that the Veteran's primary risk factor is continuous use of tobacco. He stated, "[a]ccording to UpToDate (below), worldwide, 21% of pancreatic cancer deaths are attributed to smoking. Thus, it is 21% likely that [V]eteran's pancreatic cancer was caused by smoking." According to the Veteran's November 2006 clinical record, he reported that he began smoking in 1982 and smoked an average of half a pack of cigarettes per day. During his March 2012 PTSD examination, he stated that he quit smoking only four years ago. Before he quit, the Veteran had a 26-year history of tobacco use. The additional medical evidence of record does not show that the Veteran's pancreatic cancer or liver disorder originated in service or is otherwise etiologically related to his active service. His clinical evaluations during service were deemed normal. The Veteran was diagnosed with pancreatic cancer in February 2013, over 20 years after the Veteran's separation from active service. In January 2020, the Appellant submitted medical articles regarding pancreatic cancer. One article suggested a link between the use of Zantac (Ranitidine) described as a popular heartburn drug - with pancreatic cancer. Additionally, the Appellant has submitted additional articles which suggest possible causes of pancreatic cancer such as obesity, diabetes or pre-diabetes, hypertension, smoking, age, race, family history, chronic pancreatitis and taking a lipid-lowering agent. One article discusses chronic use or abuse of alcohol as being associated with an increased risk of developing any type of cancer, but a particularly high association with esophageal cancer and liver cancer. Further, one article discuss that abuse of anabolic steroids most often associated with individuals trying to increase performance of athletic endeavors or body enhancement through body building had an increased risk for pancreatic cancer. Another study identified alcohol use particularly among men as one of the top 5 pancreatic cancer risk factors. Another study noted that more than half of patients with pancreatic cancer had psychological symptoms as early as 43 months before physical symptoms of pancreatic cancer, but further noted that the link between depression and pancreatic cancer is not entirely clear. Based on the entirety of the record, the Board finds that the preponderance of the evidence establishes that neither service-connected PTSD nor any other service-connected disorder was a principal or contributory cause of the Veteran's death, nor did such disabilities hasten his death. The evidence in support of the claim includes the December 2015 registered nurse statement reflecting a "belief" that the Veteran's alcoholism and drug abuse was caused by PTSD which led to pancreas and liver problems. This statement has probative value as it was rendered by a competent provider of treatment. However, the examiner does not specifically reference any specific facts to support this opinion or offer more than a conclusory statement. This examiner also vaguely referenced that it is "possible" the above-described disabilities were caused by "time in service" without any specific facts or rationale to support this aspect of the opinion. The Board notes that "possible" is speculative in nature. See Bostain v. West, 11 Vet. App. 124, 12728 (1998) (quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993)) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). On the other hand, the record reflects the onset of pancreatic cancer and liver disorder many years after service. The 2020 VA examiner provided an extensive rationale supporting the opinion that it was less likely than not that the Veteran's pancreatic cancer, which caused his subacute liver failure, had its origin in alcohol consumption. The examiner reasoned that "the role of alcohol in pancreatic cancer is minimal - apparently the same magnitude as coffee consumption" and, with reference to medical literature, cited the likelihood of alcohol having caused pancreatic cancer as being smaller than 6.2%. The examiner considered that the possibility that alcoholic pancreatitis could be the cause of pancreatic cancer, but found no evidence in the record that the Veteran actually had pancreatitis. In addition, the examiner reviewed the Veteran's liver enzymes and found that most of the liver enzyme abnormalities most closely associated with alcohol abuse were not seen prior to the Veteran's diagnosis of pancreatic cancer. The Board finds that the 2020 VA examiner's opinion greatly outweighs the registered nurse statement. The Board also finds limited probative value to the medical articles submitted by the Appellant. There is no competent evidence that the Veteran was prescribed Zantac to treat his service-connected disabilities he was not service-connected for a disorder such as gastroesophageal reflux disease. Therefore, the theory that the use of Zantac contributed the Veteran's death has no probative value with respect to his death being service-connected in origin. With respect to alcohol use and chronic pancreatitis as being causes of cancer, the probative value of the medical articles is limited as they do not address the factual background in this case and such information is greatly outweighed by the VA medical opinion which considered these risk factors, including the possibility of chronic pancreatitis as well as the effects of the Veteran's alcohol use on his cause of death with the examiner noting the likelihood of alcohol having caused pancreatic cancer was smaller than 6.2%. With respect to the articles discussing tobacco use, the Board notes that a disability or death will not be considered service-connected on the basis that it resulted from injury or disease attributable to the veteran's use of tobacco products during service. 38 U.S.C. § 1103; 38 C.F.R. § 3.300(a). Service connection is allowed if the Veteran's nicotine dependence is attributable to a service-connected disability after service. VAOPGCPREC 6-2003 (October 28, 2003). However, nicotine dependence was finally denied in a January 1998 rating decision, and there is no competent evidence of record suggesting nicotine dependence is due to a service-connected disability. As such, the Board finds no duty to obtain opinion on a theory that nicotine dependence was proximately due to service-connected disability. 38 C.F.R. § 3.159(c)(4). The Board next notes that there is no competent evidence suggesting that the Veteran used anabolic steroids due to service-connected disability, and the tenor of the article regarding a higher association of depression in individuals with pancreatic cancer does not suggest that depression actually has a relationship in causing pancreatic cancer. Thus, these theories have no probative value. Furthermore, the Appellant seems to theorize that the Veteran's pancreatic cancer is related to "Gulf War Syndrome" apparently related to immunizations, but this theory is not clear. The Veteran's only overseas service was a deployment to Germany. The Appellant has not submitted any competent evidence suggesting that any immunization received by the Veteran may have caused or contributed to disability leading to his death. As such, medical opinion on this theory is not warranted. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (a claimant's mere "conclusory generalized statement" that an in-service illness caused his current disability did not trigger VA's requirement to obtain an examination, and it rejected the theory "that medical examinations are to be routinely and virtually automatically provided to all veterans in disability cases involving nexus issues"). Overall, while some of the information within the medical articles submitted by the Appellant has some probative value, the Board finds that this probative value is greatly outweighed by the March 2020 VA examination which is factually specific to the Veteran's cause of death claim. See Herlehy v. Brown, 4 Vet. App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). Lastly, the Board has considered the Appellant's contentions that the Veteran's PTSD caused/aggravated his alcoholism, which subsequently caused his liver failure and pancreatic cancer. She recalls the Veteran being told that he had low liver enzymes and needed to stop drinking. The Veteran also reported being told that he had elevated liver enzymes while he was alive. Their recollection of doctor statements have some probative, but that value is limited as the Board cannot determine the degree of certainty for this type of opinion or the specific information relied upon. On the other hand, the VA physician specifically reviewed the Veteran's laboratory results including the Veteran's own report to VA examiners of a history of elevated liver function tests, and opined that the liver enzyme abnormalities most closely associated with alcohol abuse were not seen prior to the Veteran's diagnosis of pancreatic cancer. The Board affords this opinion substantially greater probative weight as the reasoning is supported by reference to actual factual data. Otherwise, the Appellant's statements alone are not competent to determine the Veteran's cause of death. The etiology of pancreatic cancer and subacute liver failure are complex, particularly when it is related to the Veteran's cause of death. This is a medical matter, requiring medical training and expertise, which is not susceptible to lay opinion. Jandreau v. Nicholson, 492 F.3d. 1372 (2007); see Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Therefore, this lay evidence has limited probative value. Upon review of the evidence of record, the Board assigns greater probative value to the March 2020 VA examination of the Veteran's medical condition and history, rendered by a licensed professional with the knowledge and expertise to provide a medical opinion on this case. Accordingly, the Board concludes that the preponderance of the evidence is against the claim of entitlement to service connection for the cause of the Veteran's death. As such, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Adeleke, 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.