Citation Nr: 21040351 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-63 184 DATE: July 3, 2021 ORDER Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for obstructive sleep apnea (OSA) is denied. FINDINGS OF FACT 1. The preponderance of evidence is against a finding that the Veteran's left shoulder disability is related to the Veteran's active duty service. 2. The preponderance of evidence is against a finding that the Veteran's prostate cancer is related to the Veteran's active duty service. 3. The preponderance of evidence is against a finding that the Veteran's obstructive sleep apnea is related to the Veteran's active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for prostate cancer, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 3. The criteria for service connection for OSA, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in active duty service with the Air Force from March 1984 to November 1984; June 19994 to October 1994; and January 2004 to January 2005 to include service in the Reserves and Southwest Asia. This matter is on appeal from a November 2015 rating decision. The Veteran was afforded a July 2020 hearing before the undersigned Judge. A transcript of the hearing has been associated with the record. The Board remanded this appeal in February 2021 for additional development. Service Connection Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Certain chronic diseases, including arthritis, may be service connected if manifested to a degree of 10 percent disabling or more within one year after separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In relevant part, 38 U.S.C. § 1154 (a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. 38 U.S.C. § 5107 (b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Left shoulder disability The Veteran asserts his left shoulder disability is related to active duty service. Review of the medical treatment record shows complaints for left shoulder pain. An August 2015 x-ray found mild acromioclavicular (AC) osteoarthritis in the left shoulder and an October 2015 VA examiner diagnosed the Veteran with left shoulder rotator cuff tear, impingement syndrome, labral tear, and AC joint osteoarthritis. As such, the Board finds the Veteran with a current disability. Review of the Veteran's service treatment records (STRs) does not show any complaints, treatments, or diagnoses for a left shoulder disability. Reserve physical examinations held in July 1987, June 1991, October 1993 and August 1998 show the Veteran did not report any "trick" shoulder, joint deformity, or arthritis; the treating physicians did not report or find any left shoulder disability. In a January 2004 pre-deployment and May 2004 post-deployment examination, the Veteran did not report any complaints for swollen or stiff joints or other complaints relating to a left shoulder disability. In a September 2005 VA examination for the left thumb, the examiner noted upon physical examination the Veteran had "no swelling of his extremities and has no pains referrable to any other joints." The examiner further noted that review of the Veteran's musculoskeletal system showed the "only abnormality" was the left thumb and assessed the Veteran's "general physical examination is normal." In an August 2009 VA medical center (VAMC) visit to establish care, the Veteran reported no medical problems or complaints other than stiffness in his left thumb. A physical examination of the Veteran's musculoskeletal system found no reported issues or assessments by the treating provider. In a December 2013 MRI test for shoulder pain, the treating provider found mild arthropathy in the AC joint, possible chronic SLAP tear, and supraspinatus tendinosis/tendinopathy. In a January 2014 new patient visit, the Veteran presented with left shoulder pain. The Veteran reported that he was pushing "an object" later described as a Chevy Cab this past October and now was experiencing pain in his left shoulder with extension and weight resistance. The treating provider assessed the Veteran with a left shoulder sprain. In a second January 2014 followup the Veteran was noted with a known partial rotator cuff and superior labral tear and reported worsening pain. The Veteran agreed to proceed with a surgical procedure for treatment, which was performed in February 2014. The Veteran made several followup visits ending in November 2014 and reported that he was doing well. In a July 2015 VAMC visit to reestablish care, the Veteran reported left arm and rotator cuff pain and indicated that he had surgery "to reattach muscles." In an August 2015 x-ray, the treating provider found mild AC osteoarthritis. The Veteran was afforded an October 2015 VA examination. The Veteran reported that in 2004 while on deployment, the Veteran was "pushing 10K pallets"; the Veteran stated that he and 8 others were unable to move pallets from C-17 aircraft and when it "finally broke loose" and the Veteran was able to grab a chain and throw it under the pallet to stop it from rolling away. The Veteran asserted that "it was the pushing that was the issue." The examiner next noted that in October 2013 the Veteran reported "pushing a Chevy Cab weighing 800 pounds ... pushing it up a trailer and the chevy started rolling back down the ramp so [the Veteran] pushed as hard as I could and pulled the muscle off the bone." The examiner opined that the Veteran's left shoulder condition came about as a result of the injury in October 2013 from pushing the Chevy Cab. The examiner stated that "none of the diagnosed left shoulder conditions...have been linked to any perceived or actual environmental exposure from military service in Southwest Asia" and found it less likely than not that the Veteran's claimed left shoulder disability was "related to a specific exposure event...during service in Southwest Asia." However, the examiner does not address the Veteran's statements on pushing pallets from C-17 aircraft and assertions that this was the issue causing his left shoulder disability. As such, the Board finds this opinion inadequate and affords it less probative weight. In an October 2015 statement submitted after the October 2015 VA examinations, the Veteran stated that he first felt the pain after pushing heavy pallets aboard C-17 aircraft in Afghanistan. In an August 2016 notice of disagreement (NOD), the Veteran stated that he did not have any shoulder problems prior to his service in Afghanistan in 2004. The Veteran stated his belief that pushing pallets "weighing up to 10,000 pounds" on and off aircraft caused initial pain to his shoulders; the Veteran stated that he did not worry about the pain at the time because he thought it was just part of the "no pain, no gain muscle building process." The Veteran next stated that later in 2012 he "pulled my left shoulder muscle from the left shoulder bone while I was pushing an 800 pound Chevy Cab onto a trailer"; the Veteran stated that this was a result of his "weakened condition" from his military service. In a September 2016 statement the Veteran indicated that as part of the "older Reservists like me", they were sent in to "just get the job done" and his unit strongly discouraged going to sick call because "we were the ones that were sent there to do the work." At the Veteran's July 2020 hearing, the Veteran testified that he injured his left shoulder from pushing pallets. The Veteran stated that he was pushing pallets weighing close to 10,000 pounds on rollers and that the "full-timers...thought it was funny if they would act like they were pushing and let me do all the work" and push the pallet on and off the C-17 aircraft. The Veteran stated that this was the start of his pain and it progressively got worse. The Veteran next testified that his left shoulder progressively became worse over the years until while trying to badge in at work his arm was unable to reach out far enough and it was found "the muscle had actually came apart" and required surgery. The Veteran's representative asked if this event occurred while on active duty, and the Veteran answered that he was in active duty from January 2004 to January 2005; however it is unclear whether the event asked by the representative referred to the left shoulder injury or the later event where he was unable to badge in at work. The Veteran stated that he tried to ignore the injury and did not go to any doctor, stating that he thought was not going to get that bad and that it would go away. The Veteran's representative asked the Veteran when he got surgery if he was ever asked if the shoulder injury was due to an older injury, the Veteran denied and stated that "the whole thing was new to me." The Veteran noted that there was "a long time in between" the first incident in 2004 and his surgery in 2013. In a March 2021 VA addendum medical opinion, the VA examiner found it was less likely than not that the Veteran's left shoulder disability was due to or incurred during active duty service. The examiner noted that the Veteran's inservice medical documentation did not show any left shoulder injury, trauma, complaints, evaluation, or work up to include imaging, diagnosis or treatment. The examiner noted that there were no profiles issued for the left shoulder or line of duty (LOD) awards for the left shoulder. The examiner indicated that the May 2004 post-deployment health assessment did not show the Veteran with any left shoulder complaints. The examiner next noted that a September 2005 VA examination found no swelling in the extremities or pain referrable to any other joints and assessment of the Veteran's "general physical examination" as normal. The examiner found that VAMC provider notes in August 2009, September 2010, and November 2011 were negative for shoulder complaints. The examiner indicated the Veteran did not present to a medical facility for a left shoulder evaluation until December 2013 for an MRI; the following January 2014 visit noted the Veteran reported suffering the shoulder injury while pushing a Chevy Cab. The examiner opined while the Veteran was deemed competent to provide a history of symptoms, the Veteran was not capable to diagnose those symptoms. The examiner noted "it would be expected the Veteran would have made mention of his shoulder complaints at any of the multiple medical visits he had during service and those soon after discharge." The examiner stated that the lack of subjective complaints along with normal physical exams meant that there was "no issue at hand to address by either the Veteran or the medical examiner" and that the injury "was clearly, by the Veteran's own report, due to pushing a Chevy Cab." As the March 2021 VA examiner provided a detailed review and examination of the Veteran's claims file, made repeated references to pertinent past records and statements consistent with the evidence of record. As such, the Board finds that the VA examination report and medical records documenting the nature and extent of the Veteran's left shoulder disability, to be the most probative evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board acknowledges the Veteran's statements that the left shoulder disability were related to his military service. Certainly, the Veteran is competent to describe experiencing symptoms in service and recurring thereafter. Indeed, treatment records corroborate at least to some extent the Veteran's history of symptoms. Nevertheless, as lay persons, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner's opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the March 2021 VA examiner considered the in-service clinical findings and his report of symptomatology thereafter. The examiner still found that it was unlikely that the Veteran's reported in-service problems were related to any current disability. The Board finds that the Veteran's opinion is outweighed by the competent opinions of the VA examiner. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). The Board first notes that service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such disease is shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for a left shoulder disability on a presumptive basis is not warranted as the record does not show evidence of arthritis of the left shoulder arose during the Veteran's period of active military service, or within one year of separation from active duty service. Notably, review of the medical treatment record shows the first medical evidence documenting any arthritis in the left shoulder was in August 2015, years after his separation from active duty. As such, the available medical evidence does not support or show that the Veteran's left shoulder disability was present to a compensable degree within a year of the Veteran's separation from service. Accordingly, service connection for a left shoulder disability on a presumptive basis is not warranted as there is no evidence of arthritis in the shoulder or that a chronic disease manifested to a degree of 10 percent or more within one year following the Veteran's separation from active military service. Based on the above, the Board finds that the competent evidence on record is against a finding of service connection for the Veteran's left shoulder disability. The Veteran's STRs show no complaints, treatments or diagnoses for a left shoulder disability. Review of the Veteran's medical treatment record shows the Veteran received treatment for left shoulder pain; however, the earliest documentation of record relating to the left shoulder was in 2013, years after the Veteran's separation from service. The March 2021 VA examiner considered the Veteran's report of symptoms during intervening years but provided reasoned analysis of the case to support their opinion that the Veteran's current left shoulder disability was not related to or caused by the Veteran's active duty service. The Veteran has not submitted any other opinions to be weighed against the VA examiner's opinion. As such, the Board finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran's left shoulder disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Prostate Cancer and Obstructive Sleep Apnea The Veteran asserts his prostate cancer and obstructive sleep apnea (OSA) is related to his active duty service. Review of the medical treatment record shows in October 2009 the Veteran was assessed with low-grade, low volume prostate cancer. A February 2015 sleep study assessed the Veteran with sleep apnea. The October 2015 VA examiner diagnosed the Veteran with prostate cancer and OSA. As such, the Board finds the Veteran with a current disability. Review of the Veteran's STRs show no complaints, treatments or diagnoses for prostate cancer or OSA. In January 2004 pre-deployment and May 2004 post-deployment health assessments, the Veteran denied complaints of feeling tired after sleeping. The Board notes the Veteran's STRs show the Veteran receiving anthrax vaccination shots in July 1999, August 1999, June 2000, January 2004, and August 2004. The Board further notes that the last two shots in January 2004 and August 2004 were administered during the Veteran's active duty service. Review of the Veteran's STRs show in March 2000 the Veteran reported possible reaction to anthrax vaccinations that he received in July 1999 and August 1999. The Veteran stated that 3 weeks after his last vaccination he developed a sore arm; the treating provider noted that the Veteran did not develop issues until one day after walking extensively he developed headache, dizziness, heart-pounding, and an ill-feeling. The Veteran stated that his symptoms eventually resolved until in December 1999 he experienced a recurrence of headache and pounding heart at home. The treating provider noted these symptoms were "characteristically brought on by exercise" and the headache did resolve. The Veteran presented his concerns that these manifestations were related to anthrax; however, the treating provider noted "to my knowledge, this does not sound like a side reaction which has been previously reported." An April 2000 consensus opinion also noted that it was against that the reported side reactions were due to the anthrax vaccinations "due to remove time and type of symptoms." The Veteran was afforded an October 2015 VA examination for the Veteran's prostate cancer and OSA. In the VA examination for prostate cancer, the Veteran reported that during a routine check in 2009 the treating provider found the Veteran with elevated levels which led to his diagnosis for prostate cancer. The Veteran reported that his current treatment was with his own "herbal solution." The Board notes the examiner did not provide an opinion. In the VA examination for OSA, the Veteran reported that his wife "quit sleeping with me a few years ago" because of his loud snoring and complaints "I was choking on my tongue and couldn't breathe"; as such the Veteran went in to get checked and was diagnosed with OSA. The Veteran noted that he does not worry about his condition and does not use the prescribed machine for treatment. The examiner noted the Veteran's OSA was diagnosed in a February 2015 sleep study and continued to not use his prescribed CPAP machine for treatment. The examiner at this time did not find the diagnosed sleep apnea to be linked to any perceived or actual environmental exposure from military service in Southwest Asia and therefore gave a negative etiology opinion relating to a specific exposure event during service in Southwest Asia. In a separate October 2015 statement from the Veteran submitted after the VA examinations, the Veteran stated that he had severe sleep apnea "which causes me to sleep during my 62 miles ride to and from work", and described having bouts of falling sleep at the wheel since his tour of duty in 2004. The Veteran next stated that he had severe fatigue due to prostate cancer and was currently considering his treatment options. In an August 2016 NOD, the Veteran asserted the stress from his active duty service caused his prostate cancer, indicating that he worked 12 to 16 hours a day for 6 days of the week during his deployment. Regarding his sleep apnea, the Veteran described an incident during his deployment where during a 16 hour shift he was found "asleep and hanging upside down by my leg" in his forklift and suffered from sleep interruptions since. In a September 2016 statement, the Veteran stated that he was totally worn out and was unable to get a full night's sleep "because of the continuous raids on the base where we were awoken from our sleep" and had to dress and report to a bunker. The Veteran added "and now I have been diagnosed with sleep apnea...I have prostate cancer which is a given as far as my claim is concerned." In a December 2016 form 9 statement, the Veteran asserted his prostate cancer and OSA were related to an adverse reaction to his anthrax vaccination. In a February 2017 private provider letter, the provider noted the Veteran presented with concerns that his chronic symptoms and current medical problems were directly related to the administration of vaccines in the 1990s. The Veteran asserted that these vaccines contained the chemical squalene and stated that squalene has been associated with a large number of medical problems as detailed in a book titled "Anthrax, a Deadly Shot in the Dark." The private provider acknowledged the Veteran had suffered from migraines, paresthesias, fatigue, erectile dysfunction, palpitation, and epistaxis over the years; the provider also noted the Veteran was considering treatment options for adrenal tumor and prostate cancer. The provider noted the Veteran brought documentation of his anthrax vaccination history from 1999 to 2004 and contends that he was actually given the vaccinations as early as 1996; the Veteran was noted to also cite books and resources that stated a correlation with anthrax immunization in the 1990s and squalene-related adverse reactions. The Veteran attributed his anthrax vaccination as the cause of his current symptoms and conditions and "desires the government conceded that the immunization may have been a cause to his ongoing health concerns...based on the allegation that his present shot record is incorrectly documented and on the many associations of anthrax immunization to a large number of symptoms and chronic conditions in the literature and internet resources." The Board notes that the provider did not provide any further opinion regarding the etiology of the Veteran's prostate cancer or sleep apnea. The Veteran included with the February 2017 private provider letter a page from a report where the Veteran hand wrote the title "the September 2002 US GAO Anthrax Vaccine Report to Congress." In an October 2017 statement from the Veteran referred to the September 2002 GAO report and stated that it "openly admits there was and is a direct military service connection between...[the] additive called squalene that was in all five of my US military anthrax shots...and my short and long term health problems...like cancer, adrenaline gland failure, depression and chronic fatigue." The Veteran asserted that his health began to decline after his third "squalene tainted anthrax in June of 1996" and indicated that his medical records for 1996 were "very conveniently missing in action." The Veteran described one of the symptoms resulting from the shot was "long-term sleep apnea and blackouts while driving for the past 20 years." The Veteran stated that riders in his carpool do not like him driving and falling asleep during the 62 mile drive to work. The Veteran noted that when he was deployed in 2004, "without my consent and without a waiver, I had to take my 4th and 5th mandatory anthrax shots"; the Veteran later stated that he was given a waiver to "never have another anthrax shot" and that the military "mysteriously lost all their anthrax shot records until they found them or moved them to 1999." The Veteran noted that squalene continues to be used in smallpox and flu shots today and asserted "if it doesn't exhibit any short-term effects, it definitely will rear its ugly head in the long run"; stating that the chemical has been associated to Gulf War syndrome in referencing the 2002 GAO report. The Veteran also submitted in October 2017 scans of pages from a book and a January 2017 article. At the Veteran's July 2020 hearing, the Veteran testified that his prostate cancer and sleep apnea were due to an anthrax reaction. The Veteran's representative referred to the Veteran's vaccinations beginning in July 1999 and his subsequent reactions to include headache, dizziness, heart pounding and ill feeling. The Veteran testified that his symptoms began in July after "my third anthrax shot was July 1996" and reiterated that the medically community had lost his 1996 record. The Veteran stated that he was told in August 1996 that he "would never have to have another anthrax shot"; but when he later changed units, "they didn't care and I got two more anyways in 2000 and 2005." The Veteran acknowledged that regarding his prostate cancer and sleep apnea, no one has directly attributed those conditions directly to his anthrax shots; the Veteran stated that "the only reason I have is because I've read a book...attributes 70 different autoimmune disease to anthrax" and explained that the chemical squalene used in the vaccine caused "your immune system to attack itself" and result in various autoimmune disease. The Veteran stated that his treating provider told him in a written statement that the sleep apnea could positively be attributed to the anthrax shot. The Veteran's representative indicated that this written statement was the February 2017 private provider letter associated with the claims record. In a March 2021 VA addendum opinion, the VA examiner indicated that the Veteran's claims record and electronic health record were reviewed. The examiner found it was less likely than not that the Veteran's prostate cancer was related to active duty service. The examiner noted that review of inservice medical records did not show any objective medical evidence that the Veteran's prostate cancer that was diagnosed in 2009 was due to his active duty service; and there were no inservice medical documentation to show "subjective complaints, signs that were clinically suspicious, and/or workups consistent with prostate cancer." The examiner next found that there was insufficient objective medical evidence to show a causal relationship between anthrax vaccination to include the component of squalene and prostate cancer. The examiner noted the definition of prostate cancer and that it has "clear and specific etiology with the main risk factors being male gender, age and genetics." The examiner noted that reference to UpToDate stated that "prostate cancer has one of the strongest relationships between age and any human malignancy" and that the incidence of prostate cancer rises rapidly with increase in age. The examiner next noted that according to the PubChem reference for the chemical squalene, the chemical has been used as a component for vaccines to enhance the immune response as well as found in a varied of foods and cosmetics. The examiner noted that squalene has been used as part of the flu vaccine with 22 million doses administered since 1997 with no severe adverse events associated with the vaccine. The examiner indicated that clinical studies on squalene-containing vaccines have been performed in infants without evidence of safety concerns. The examiner acknowledged that "one of the many possible exposures suspected o causing chronic multi symptom illness of Gulf War Veterans is squalene, thought to be present in anthrax vaccines"; however, the examiner noted that further studies did not find any association between squalene antibody status and chronic multi-symptom illness. Regarding sleep apnea, the examiner found it was less likely than not that the Veteran's sleep apnea was related to active duty service to include due to receiving the anthrax vaccination. The examiner found that active duty medical documentation did not show any clinical suspicion of sleep apnea, and no complaints, evaluations, workups, diagnoses or treatment for suspected sleep apnea. The examiner gave a definition of the characteristics of sleep apnea and noted that sleep apnea had a clear and specific etiology, "none of which is due to and/or caused by anthrax vaccination." The examiner stated that review of current medical literature did not show any causal relationship between the anthrax vaccination and the development of OSA. The examiner considered the Veteran's statements where he described being worn out from never getting a full night's sleep as a result from continuous raids at the base where he was stationed and stated that these were "not clinically suspicious and/or typical complaints of sleep apnea." The examiner found the Veteran's complaints to be "directly attributed to poor sleep hygiene...due to interrupted and non-continuous hours." The examiner noted the "gold standard for diagnosing sleep apnea is [a sleep study]" which the Veteran did not undergo until 2015, years after his separation from service. The Board notes in February 2017 and October 2017 the Veteran submitted book scans, articles, and a report that discussed anthrax vaccinations and squalene. The Board further notes that an adequate medical opinion should consist of a thorough review of the claims file and a discussion of the relevant evidence (including the disability in question), a consideration of the lay contentions of the veteran, and clear conclusions with a reasoned supporting rationale. Nieves-Rodriguez, 22 Vet. App. at 301. However, a medical opinion does not have to be perfect; and there is no requirement that a medical examiner comment on every piece of evidence in a claims file. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). The law imposes no reasons-or-bases requirement on examiners. Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Where a medical opinion is lacking in detail, the Board is permitted to draw inferences based on the overall report, so long as the inference does not result in a medical determination. Id. at 294. Here, the March 2021 VA examiner noted that they reviewed the Veteran's claims folder and medical history, considered his report of symptoms before rendering the medical opinion, and cited to the facts and medical record in support of their findings. The Board infers that the March 2021 VA examiner did not find the Veteran's submissions to include the February 2017 and October 2017 articles sufficiently important for the purposes of their analysis. The Board further finds that the February 2017 and October 2017 articles submitted by the Veteran in support of his claim are insufficient to establish the required medical nexus between his prostate cancer and sleep apnea to his active duty service. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159 (a)(1). However, treatise evidence must not simply provide generic statements that are 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 such a degree of certainty that, under the facts of a specific case, there is at least plausible causality based upon objective facts, not an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314, 317 (1998). The Board finds that the articles submitted by the Veteran has little probative weight because they do not specifically discuss a relationship between the Veteran's prostate cancer and sleep apnea to the Veteran's active duty service with a degree of certainty. See id. The Board also finds that the generalized article information is outweighed by the March 2021 VA medical opinion, which was rendered by a medical professional who reviewed the Veteran's complete claims file, reflected on the specific facts of his case, considered pertinent medical research, and furnished a thorough rationale for their conclusions. See Nieves-Rodriguez, 22 Vet. App. 295. The Board infers that the March 2021 VA examiner did not find the Veteran's submissions to include the February 2017 and October 2017 articles sufficiently important for the purposes of their analysis. As the March 2021 VA examiner provided a detailed review and examination of the appellant's claims file, made repeated references to pertinent past records to include the appellant's STRs, and statements consistent with the evidence of record, the Board finds that the March 2021 VA examination report and medical records documenting the nature and extent of the appellant's prostate cancer and sleep apnea, to be the most probative evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board acknowledges the Veteran's statements and assertions that his prostate cancer and sleep apnea is related to his military service. Certainly, he is competent to describe experiencing symptoms. To the extent that the Veteran contends that a medical relationship exists between his claimed current disability and service the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner's opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the VA examiner considered the Veteran's statements and reports of symptoms. The examiner still found that it was unlikely that his reported in-service symptoms were related to any current disability. The Board finds that the Veteran's opinion is outweighed by the competent opinion of the VA examiner. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). After review of the record, the Board finds the competent evidence of record is against a finding of service connection for the Veteran's prostate cancer and sleep apnea. Review of the Veteran's STRs show no complaints, treatments or diagnosis relating to prostate cancer or sleep apnea. Review of the medical treatment record shows the earliest competent documentation relating to the Veteran's prostate cancer condition was in October 2009 and February 2015 for the Veteran's sleep apnea, years after the Veteran's separation from service. The Veteran has reported suffering adverse reactions from anthrax vaccinations beginning from 1996 to include receiving a waiver from future anthrax vaccinations. However, review of the claims record shows documentation of the Veteran's anthrax vaccinations beginning in 1999 through 2004 and no documentation of the claimed waiver. In addition, although the Veteran reported symptoms of a claimed adverse reaction following vaccinations in 1999 in 2000, the Board notes that the vaccinations in 1999 did not occur during a period of active duty service and provider opinions during that period did not find the Veteran's reported symptoms to be related to the anthrax vaccinations. Furthermore, the Board notes that following the Veteran's anthrax vaccinations in January 2004 and August 2004 there were no complaints of adverse reactions in the pre-deployment and post-deployment health assessments or in the August 2009 VAMC visit to establish care. The March 2021 VA examiner considered the Veteran's report of symptoms during intervening years but provided reasoned analysis of the case to support their opinion that the Veteran's current prostate cancer and sleep apnea was not related to or caused by the Veteran's active duty service to include from anthrax vaccinations. The Veteran has not submitted any other opinions to be weighed against the VA examiner's opinion. As such, the Board finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran's prostate cancer and sleep apnea. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.