Citation Nr: 21031568 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 16-20 195 DATE: May 24, 2021 ORDER Service connection for a heart disorder, including atrial fibrillation, is denied. Service connection for residuals of prostate cancer is denied. FINDINGS OF FACT 1. The Veteran's heart disorder, including atrial fibrillation, is not linked to disease or injury incurred or aggravated in active service, including burn pit exposure. 2. The Veteran's prostate cancer, currently in remission with residuals of voiding dysfunction, is not linked to disease or injury incurred or aggravated in active service, including burn pit exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disorder, including atrial fibrillation, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for residuals of prostate cancer have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1953 to January 1955. These claims come before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The Board reopened the claims in a March 2018 decision and remanded them for further development. It remanded the claims again in November 2018, August 2019, May 2020, and September 2020. The Veteran testified at a hearing before the undersigned Veterans Law Judge in January 2018. A transcript of the hearing is of record. Service Connection Service connection generally will be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link between the current disability and the disease or injury incurred or aggravated in service (the "nexus" element). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). For the chronic diseases listed in 38 C.F.R. § 3.309(a), including malignant tumors and cardiovascular-renal disease, service connection may alternatively be established with evidence of chronicity of the disease during service or during a presumptive period following service separation. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015). For conditions noted during service (or in the presumptive period) but not shown to be chronic at the time, a continuity of symptomatology after service is required to support the claim. 38 C.F.R. § 3.303(b). When chronicity or continuity is established, subsequent manifestations of the same chronic disease at any later date, no matter how remote in time from the period of service, will be service connected unless clearly attributable to causes unrelated to service ("intercurrent" causes). Id. In addition, where a veteran served continuously for 90 days or more during a period of war, or after December 31, 1946, there is a presumption of service connection for malignant tumors and cardiovascular-renal disease if the disease manifested to a degree of 10 percent or more within one year from the date of separation from service, even if there is no evidence of the disease during the service period itself. 38 U.S.C. § § 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). This presumption may be rebutted by affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (when the evidence supports the claim or is in relative equipoise, the claim will be granted). Heart Disorder and Residuals of Prostate Cancer The Veteran claims service connection for a heart disorder and prostate cancer residuals. He states that these conditions were caused by exposure to chemicals and asbestos from a burn pit during active service. See February 2014 Correspondence. More specifically, he states that while stationed at Landes de Bussac, France, from 1953 to 1955, there was a period of at least seven months when his duties included disposing of hazardous waste material, including asbestos and "all kinds of toxic waste" at a dump site where these were burned. He states that he had exposure to the burning waste on a daily basis without any protection. See id. After carefully considering the record, including the Veteran's statements and the evidence submitted by him, as discussed below, the Board finds that service connection is not established for his heart condition and prostate cancer residuals. Before addressing the merits of the claims, the Board notes that, unfortunately, the Veteran's service personnel records were destroyed in a fire that occurred at the National Personnel Records Center (NPRC) in 1973, according to a response from that agency to VA's request for records. See July 2011 VA 21-3101. When service department records are lost or missing while in government control, VA has a heightened duty to assist in developing the claim, as well as to consider the applicability of the benefit of the doubt rule and to explain its decision. Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005). While the NPRC stated that the Veteran's service treatment records were destroyed as well, the claims file shows that they were added to his claims file in 1955. With regard to the Veteran's heart condition, the record shows diagnoses of atrial fibrillation and, more recently, valvular heart disease. See May 2016 VA Examination Report; October 2020 VA Examination Report. A January 2016 private treatment record reflects diagnoses of paroxysmal atrial fibrillation and hypertensive heart disease. The Veteran's prostate cancer was diagnosed and treated with radiation therapy in 2007. See August 2018 VA Examination Report; October 2020 VA Examination Report. During the pendency of this claim it has been in remission, with residuals consisting of voiding dysfunction. See id. In a February 2013 decision, and in its remands, the Board found it plausible that the Veteran's duties included disposing of refuse in a burn pit while stationed in France, and that he had some exposure to fumes from the burn pits. The private treatment records show that the Veteran was first diagnosed with adenocarcinoma of the prostate in January 2007, on biopsy, after laboratory testing detected an elevated prostate-specific antigen (PSA). At that time, he reported being in good general health without major medical or surgical problems. It was treated with radiation therapy, and has been in remission during the pendency of this claim. The service treatment records do not show a prostate condition at the time, and the record, including the Veteran's statements, does not otherwise indicate that his prostate cancer manifested prior to 2007. With regard to the Veteran's heart condition, the private treatment records show an initial diagnosis of atrial fibrillation in August 2008. These records include an abnormal EKG study that was performed in April 2008. A June 2011 VA examination report states that the Veteran has had atrial fibrillation since at least 2008. A February 2007 private treatment record notes a history of hypertension and hyperlipidemia, but no history of heart disease. However, a January 2016 letter by the Veteran's treating cardiologist reflects a diagnosis of hypertensive heart disease. The Veteran has also been diagnosed with valvular heart disease since 2020. See October 2020 VA Examination Report. The service treatment records do not show a heart condition at the time, and the record, including the Veteran's statements, does not otherwise indicate that his atrial fibrillation manifested prior to 2008, or that his valvular heart disease manifested prior to 2020. There is no indication that any other heart condition or potential precursor of such manifested during service or within a year of separation. The Veteran has submitted several letters by private treating physicians in support of the claims. An April 2011 letter from T. Hopkins, MD, states that the Veteran was his patient, and had been diagnosed with adenocarcinoma of the prostate in January 2007. He received Lupron therapy and radiotherapy, and had done well since then. Dr. Hopkins then stated, "We don't know the cause of the prostate cancer, but it is noted that he was exposed to asbestos and multiple chemicals while in the service. It is conceivable that these may have been contributing factors to his cancer." An October 2012 letter by Dr. Hopkins is identical to the April 2011 letter, except that it concludes that "[i]t is at least as likely as not that the exposure to the chemicals may have caused the prostate cancer." A January 2016 letter by the Veteran's private treating cardiologist, C. Haffajee, MD, states that he had been treated the Veteran for hypertensive heart disease, paroxysmal atrial fibrillation, and diffuse lung disease. Dr. Haffajee wrote that he "gather[ed]" that the Veteran was exposed to a "variety of potential toxic substances during his service in North Korea." The physician then stated, "As a result, my clinical impression is that [the Veteran's] lung disease and probably his atrial fibrillation [are] related to the exposure he had." A May 2016 letter by R. Maloney, MD, states that a review of the Veteran's symptoms "reveals that he was expose[d] to multiple toxic substances while serving in the military in Korea." Dr. Maloney concluded, "I believe it more likely than not that this toxic exposure contributed to his lung disease and atrial fibrillation." In an August 2019 letter, Dr. Maloney wrote that it had come to his attention that while serving in the military, the Veteran's duties included tending to the fire pit to dispose of all combustible waste produced by his unit. "Accordingly, he was exposed to smoke containing any number of toxic substances." Dr. Maloney concluded that "[a]s evidenced by oncologic hazards faced through fire fighting [sic], it seems reasonable that [the Veteran's] prostate cancer be considered service-connected." The Veteran has also submitted articles that discuss potential links between environmental exposures and cancer, including prostate cancer, and cardiac arrythmias. A number of these articles address exposure to burn pits in the Persian Gulf and adverse health outcomes. The Board will briefly review some of this evidence. A report by the National Institute of Health (NIH) published in 2008, titled "Environmental and Occupational Causes of Cancer New Evidence, 2005-2007," reviews then recent epidemiological evidence linking occupational and environmental exposures with cancer, including prostate cancer from exposure to pesticides, polyaromatic hydrocarbons (PAHs), and metal working fluids or mineral oils. The report states that a very large cohort study of workers exposed to polychlorinated biphenyls (PCBs) during the manufacture of electrical capacitators revealed a positive trend for prostate cancer mortality with increasing cumulative exposure. A strong dose response was observed and the trend was significant when 10-year and 20-year exposure lags were considered. Resulting prostate cancer risks were also significant at higher exposure levels. Additional evidence supported a link between exposure to some types of metals and prostate cancer, such as cadmium exposure. "Weak evidence" supported links between prostate cancer and exposure to other non-defined metals based on two recent studies. Prostate cancer was slightly increased based on exposure to metal fumes. The risk was "non-significantly increased" based on "non-substantial" exposure to toxic metals, but not for "substantial" exposure. There was a modest elevation of prostate cancer risk with increasing cumulative exposure to soluble and straight mineral oils that occurred 5 years or more before diagnosis. In a study of auto-industry workers, the risk of prostate cancer increased with exposure to straight fluids form puberty to early adulthood, with a strong association noted between exposure to straight fluids between the ages of 23 and increased risk of prostate cancer after age 50, which suggested that early adulthood exposures are critical to prostate cancer risk later in life. The results were "somewhat limited" in that the investigators were unable to control for family history of prostate cancer. A case-control study showed that no significant increased risk of prostate cancer was identified associated with lifetime cumulative PAH exposure from a variety of occupational sources, although the risk was suggestively elevated based on PAH exposure via inhalation to petroleum and via a cutaneous route of exposure to coal. Men under age 60 who carried a particular gene variant (GSTP1 Val variant) and were exposed to high levels of PAHs were at a significant increased risk of prostate cancer. Evidence regarding the risk of prostate cancer associated with solvents, although limited, was emerging. One study of aerospace industry workers found a significant dose-response trend of prostate cancer among workers exposed to low/moderate and high levels of TCE. The same study found evidence of increased risk of prostate cancer associated with exposure to benzene, but only based on high exposures and only when exposure was not lagged. Additional studies examining specific occupations and/or exposures and risk of, or mortality from, prostate cancer found significant elevations among California firefighters, petroleum workers, and semiconductor workers involved in facilities/laboratories. The Veteran also submitted a toxicological report on diesel fuel, which states that there is "no unequivocal evidence to link diesel with the incidence of cancer in humans," but there is "limited evidence for carcinogenicity in animals following prolonged exposure." The report further states that in a multi-site, case-control study, there was evidence for an increased risk of prostate cancer and squamous cell carcinoma of the lung, but this effect could not be attributed to any particular chemical. The report also notes that it "has been stated" that inhalation of diesel vapor may lead to central nervous system /respiratory depression and cardiac arrhythmias, but that there do not appear to be any specific studies to confirm these effects. A report by the Institute of Medicine (IOM) of the National Academies titled, Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan, notes that open-air waste burning has long been used by the military when other waste-disposal options have not been available. The uncontrolled burning of waste pits has been the primary solid-waste management solution in Afghanistan and Iraq from the beginning of the conflicts in 2001 and 2003, respectively, according to the report. The IOM report focused on exposure to smoke from the burn pit at Joint Base Balad (JBB), one of the largest U.S. military bases in Iraq. It based its conclusions regarding the long-term consequences of exposure to emissions from burn pits in Iraq and Afghanistan on three sources of information: data on air monitoring at JBB, health-effects information on chemicals detected in more than 5% of the air-monitoring samples at JBB, and health-effects information on populations considered to be surrogates of military personnel exposed to combustion products from burn pits: firefighters, municipal incinerator workers, residents who live near incinerators, and veterans of the 1990-1991 Persian Gulf War who were exposed to smoke from oil-well fires. The IOM report notes that the air-monitoring data suggests that the pollutants of greatest concern at JBB may be the mixture of chemicals from regional background and local sources that contributed to high particular matter. In other words, these were sources "other than the burn pit." The committee who authored the report concluded that it was unable to say whether long-term health effects are likely to result from exposure to emissions from the burn pit at JBB. However, the committee noted that air pollution exposure from service in Iraq and Afghanistan, and not just exposure to burn pit emissions, might be associated with long-term health effects, particularly in highly exposed populations (such as those who worked at the burn pit) or susceptible populations, such as those with asthma, mainly because of the high ambient concentrations of particular matter from both natural and anthropogenic, including military, sources. If that broader exposure to air pollution turned out to be sufficiently high, potentially related health effects of concern were respiratory and cardiovascular effects and cancer. The Veteran also submitted other articles discussing potential links between respiratory conditions such as chronic obstructive pulmonary disease (COPD) and burn pit exposure. See, e.g., "Vets More at Risk for COPD." The Board finds these are not relevant to the issue of whether his prostate cancer or atrial fibrillation are linked to burn pit exposure. The Board notes that VA's Public Health website states that waste products commonly disposed of in open burn pits in the Southwest Asia theater of military operations, such as Iraq and Afghanistan, included chemicals, paint, medical and human waste, metal and aluminum cans, munitions and exploded ordnance, petroleum and lubricant products, and plastic, rubber, wood, and food waste. http://www.publichealth.va.gov/exposures/burnpits/. A medical opinion by a VA physician was provided in October 2020, and an addendum to that opinion was provided by the same physician in February 2021. The opinions are based on a review of the Veteran's medical history, including prior VA examinations, and also reflect consideration of the articles submitted by the Veteran, such as those discussed above. The physician found that a relationship was not established between the Veteran's prostate cancer and atrial fibrillation or valvular heart disease and any potential in-service environmental exposures from burn pit emissions, including any potential asbestos or chemical exposure. In the October 2020 report, the physician explained that asbestosis can cause metastatic prostate cancer, but that there is no diagnosis of primary asbestosis in the Veteran's case. The physician further noted that asbestosis is associated with cardiovascular disease, but explained that the Veteran had an arrhythmia known as atrial fibrillation, which is not a cardiovascular disease. In the February 2021 report, the physician stated that although the Veteran's duties in France included working at a garbage dump and burn pits, where he was required to dispose of and burn waste, to include chemical waste, asbestos, diesel fuel, and volatile chemicals for six or seven months, and was in the vicinity of the burn pits for eighteen months, there is no medical evidence from any medical literature available that substantiates a clear connection between any in-service chemical and hazardous waste exposure and his prostate cancer, atrial fibrillation, or valvular heart disease. In this regard, the physician noted that the literature stated that "there is inadequate/insufficient evidence of an association between exposure to combustion products" and cancer or circulatory disease. The physician concluded that the Veteran's prostate cancer was likely attributed to aging, and that his atrial fibrillation was also likely due to aging and deterioration of his cardiac function. The etiology of the Veteran's valvular heart disease was unknown, according to the physician. The Board notes that previous VA medical opinions obtained in connection with this claim also attributed the Veteran's prostate cancer and atrial fibrillation to aging and other factors. For example, the November 2019 VA medical opinion states that prostate cancer and atrial fibrillation are common conditions. The chief risk factor for prostate cancer is increasing age, and the chief risk factors for atrial fibrillation include age and cardiovascular disease. The opinion notes in this regard that the Veteran had both these chief risk factors when he was diagnosed with prostate cancer and atrial fibrillation -namely increasing age and cardiovascular disease. Similarly, an October 2012 medical opinion from a VA physician specializing in occupational medicine states that the most common denominator in the occurrence of atrial fibrillation is underlying heart disease, including hypertensive heart disease, and age. The physician noted in this regard that one study showed that the risk of developing atrial fibrillation from age 40 to age 95 in men was 26 percent. The physician also stated that prostate cancer is the third most common cancer in males, and that well established etiologies include age and "genetic/family history." The physician stated there was no documented association between asbestos exposure and prostate cancer or atrial fibrillation, and no statistically significant association to support a causal relationship between the other reported environmental exposures and the Veteran's prostate cancer or atrial fibrillation. The Board finds that the preponderance of the evidence weighs against a link between the Veteran's potential environmental exposures during active service and the development many years later of his atrial fibrillation, valvular heart disease, and prostate cancer. The opinions by private physicians submitted by the Veteran are not probative on the issue because they generally lack an explanation in support of the conclusion reached. Moreover, they do not account for the fact that these are common conditions, as noted in the November 2019 and October 2012 VA medical opinions, and that the Veteran had two "chief" risk factors for developing these conditions when they were diagnosed namely advancing age and hypertensive heart disease (the latter diagnosis is shown in the January 2016 letter by Dr. Haffajee). The October 2012 medical opinion notes that prostate cancer is the third most common cancer in males, and that well established etiologies include age and "genetic/family history." Although it is unknown whether he had a genetic or family history of prostate cancer, he was well into his seventies when diagnosed with prostate cancer and atrial fibrillation, and had a history of hypertension when diagnosed with atrial fibrillation. The private medical opinions do not account for these factors. The August 2019 letter by Dr. Maloney cites the "oncologic hazards faced through fire fighting" but does not explain how that observation supports a link between the Veteran's prostate cancer and any potential in-service environmental exposures. The fact that firefighting may be associated with an elevated risk of developing some cancers, including prostate cancer, is not in itself adequate to support a link between the Veteran's prostate cancer and exposure to burn pit emissions. In this regard, for example, the IOM report discussed above was based in part on consideration of health effects of professionals such as firefighters "considered to be surrogates of military personnel exposed to combustion products from burn pits." The IOM report concluded that it was unable to say whether long-term health effects are likely to result from exposure to emissions from the burn pit at JBB, which was the Iraq base that was the focus of that report as representative of burn pits in Southwest Asia in general. The February 2021 VA medical opinion also notes that studies have found "inadequate/insufficient evidence of an association between exposure to combustion products" and cancer or circulatory disease." The August 2019 opinion by Dr. Maloney does not otherwise explain how the "oncologic hazards" of firefighting support a link between the Veteran's prostate cancer and burn pit exposure, or account for the fact that this is the third most common type of cancer in men (according to the October 2012 VA medical opinion), and was diagnosed when the Veteran was in his seventies, with advanced age being an established risk factor for prostate cancer. Accordingly, as the private medical opinions do not account for the significant risk factors the Veteran had for developing prostate cancer and atrial fibrillation, and are not otherwise supported by an adequate explanation, they carry no probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (holding that the probative value of a medical opinion comes from its reasoning, and that critical pieces of information from a claimant's medical history can lend credence to the opinion of a medical expert who considers them, and detract from the medical opinions of experts who do not). In addition, the opinions assuming that the Veteran had environmental exposure to toxins in Korea are factually inaccurate, and thus lack probative value on that basis as well. In either case, none of the opinions are probative due to their deficient or absent reasoning. The literature submitted by the Veteran, as reviewed above, is also not probative on the issue of whether a link exists between his prostate cancer and atrial fibrillation or valvular heart disease and potential in-service environmental exposures. Some of the articles and reports, such as the NIH report, discuss studies showing an elevated incidence of cancers, including prostate cancer, in those with occupational exposures to environmental factors such as pesticides, polyaromatic hydrocarbons (PAHs), and metal working fluids or mineral oils. However, those exposures, including from firefighting, are not shown to translate into the types of exposure the Veteran may have had from burn pit emissions in France in 1955. As found in the IOM report, for example, which focused on the potential health effects of exposure to burn pit emissions at JBB, environmental exposure from regional background and local sources that contributed to air pollution, and thus from sources other than the burn pit, were of "greatest concern." The committee was "unable to say whether long-term health effects are likely to result from exposure to emissions from the burn pit at JBB." Of course, the fact that there were other air pollutants in Iraq in the early 2000's that may have been a factor in adverse health outcomes does not indicate that the Veteran was similarly exposed, since his service was in the south of France in the 1950's a completely different geographic region and a half century earlier. The Board also finds it significant that the nature and extent of any environmental exposures the Veteran may have had during service remains completely unknown. The types of pollutants detected in the vicinity of burn pit emissions in Iraq in the early 2000's, or the pesticides, diesel, PAH's, VOC's, metal working fluids, etc. mentioned in the studies regarding occupational exposures associated with elevated incidents of cancer, may not have been burned or disposed of at the airfield in Southern France in the 1950's. Indeed, although the Veteran later stated that asbestos was burned, for example, he testified at an April 2011 hearing before the undersigned that he did not know what the chemicals were. Treatise evidence such as the articles and reports discussed above generally provides little support for a claim unless it is accompanied by a medical opinion which favorably applies the principles of the article to the specific facts of the case. See Sacks v. West, 11 Vet. App. 314, 317 (1998). As explained above, the private medical opinions submitted by the Veteran do not apply the principles discussed in the article to the specific facts of his case. At most, the August 2019 letter by Dr. Maloney cites the "oncologic hazards" of firefighting, but that in itself is not sufficient explanation, as already discussed. Medical articles or treatise evidence, standing alone, can support a claim if they discuss generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible argument for causality based upon objective facts rather than an unsubstantiated lay medical opinion. Id. (citing Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996)). As just discussed, the articles and reports submitted by the Veteran concern findings that are only tangentially relatedif related at allto his service in Southern France in the 1950's. The report by the IOM regarding the burn pit at JBBa stand-in for burn pits in generalreflects the conclusion that it was unable to say whether long-term health effects are likely to result from exposure to emissions from the burn pit at JBB, and notes that environmental pollutants from factors other than the burn pit, and which were specific to the region, were of "greatest concern." Thus, that report does not support the claim. The Veteran's own belief that his prostate cancer or atrial fibrillation are related to in-service environmental exposures is not competent evidence, as this is a complex determination requiring medical expertise. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). He is not shown to have such expertise, and thus is considered a lay person in the field of medicine. Therefore, his lay statements expressing a belief that his prostate cancer or atrial fibrillation are related to burn pit exposure during active service are not probative on the issue. See Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). With regard to the medical complexity of the issue, a period of over fifty years elapsed between his service and the diagnoses of his prostate cancer and atrial fibrillation, without any known earlier manifestation of these conditions. Thus, any potential relationship to in-service environmental exposures cannot be perceived through the senses alone. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The articles and reports reviewed above also indicate the complexity of the issue. To the extent the Veteran's belief that his prostate cancer and atrial fibrillation are linked to his service is based on the private medical opinions and the articles and reports he submitted, the Board has explained above why these are not probative, or not sufficient to establish such a relationship. The October 2020 and February 2021 VA medical opinions are probative, as they represent the conclusion of a medical professional based on review of the Veteran's medical history, and are supported by explanations specific to that history, and which enable the Board to make a fully informed decision. With regard to any potential in-service asbestos exposure, they explain that because the Veteran has not had asbestosis, his prostate cancer and heart conditions are not linked to asbestos exposure. With regard to potential in-service exposure to other hazardous material from burn pits, the February 2021 opinion explains that available studies are not sufficient to support a link between such exposure and the Veteran's prostate cancer, atrial fibrillation, or valvular heart disease. The physician found that the prostate cancer and atrial fibrillation were likely due to aging, and that the etiology of the Veteran's valvular heart disease was unknown. That opinion is in keeping with prior VA medical opinions obtained in connection with this claim, which state that aging is a "chief risk factor" or "established etiolog[y]" for prostate cancer and atrial fibrillation, that these are common conditions, that the risk of developing atrial fibrillation from age 40 to age 95 in men is 26 percent, and that prostate cancer is the third most common cancer in males. There is no indication that the Veteran's prostate cancer or atrial fibrillation manifested in an unusual manner. Rather, the diagnoses of these conditions when the Veteran was well into his seventies is consistent with the fact that aging is a chief risk factor for these conditions. The diagnosis of atrial fibrillation is also consistent with the fact that the Veteran had a history of hypertension or hypertensive heart disease, which is another risk factor, according to the November 2019 VA medical opinion. The February 2021 VA medical opinion specifically found that these conditions were likely due to the Veteran's aging. In sum, the VA medical opinions outweigh the private medical opinions, which lack probative value as explained above. They also outweigh the articles and reports he submitted, since these also have little probative value, and are not specific to the Veteran's history. By contrast, the VA medical opinions are specific to the Veteran's medical history, and reflect consideration of the evidence he submitted. In sum, the preponderance of the evidence weighs against a link, or nexus, between the Veteran's prostate cancer and atrial fibrillation and an in-service disease or injury, including potential exposure to environmental toxins from burn pit emissions. Therefore, the criteria for service connection on a direct basis are not satisfied. See Holton, 557 F.3d at 1366. As the Veteran's prostate cancer and atrial fibrillation were not noted during service or within a year of separation, service connection is not established on a presumptive basis. See 38 U.S.C. § 1112; 38 C.F.R. §§ 3.303(b), 3.307. The Board has considered the applicability of the benefit-of-the-doubt doctrine. In order for the benefit-of-the-doubt rule to apply, there must be a "reasonable doubt," which is one that exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. Here, there is no such approximate balance. The evidence supporting the claim has little or no probative value, as explained above. At most, it provides support for a "remote possibility" of a link to service, which is not sufficient to raise a reasonable doubt. See id. Conversely, the October 2020 and February 2021 VA medical opinions constitute probative evidence weighing against a link between the Veteran's claimed conditions and his period of service. These opinions are bolstered by the earlier VA medical opinions obtained in connection with these claims. Thus, the negative evidence substantially outweighs the positive evidence, and indeed satisfactorily disproves the claim by showing that the Veteran's prostate cancer and atrial fibrillation are likely caused by factors unrelated to service. (Continued on next page) Accordingly, because the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.