Citation Nr: 21041769 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-23 510 DATE: July 10, 2021 REMANDED Entitlement to service connection for pancreatic cancer is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1965 to October 1968. The Veteran died in April 2016; the Appellant is his surviving spouse, who was properly substituted as claimant. See 38 U.S.C. § 5121A. This matter comes before the Board of Veterans Appeals (Board) on appeal from a March 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in June 2019, to obtain a new VA medical opinion regarding the etiology of the Veteran's pancreatic cancer. The Board found that the previous examination, from January 2016, gave an inadequate rationale for its conclusions. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Specifically, the January 2016 examiner acknowledged a strong correlation between pancreatic cancer and diabetes mellitus, type II, but found that it was less likely than not that the Veteran's service-connected diabetes caused his pancreatic cancer, as "this [correlation] is often attributed to the pancreatic cancer causing the diabetes [rather than the other way around]. The Board found this rationale inadequate as it did not acknowledge that the Veteran's diabetes diagnosis predated his pancreatic cancer diagnosis by 13 years. "The examiner's opinion represented a generalized medical treatise rationale not tailored to the facts of the Veteran's case," including facts that directly contradicted the examiner's conclusion. The February 2020 examination, conducted following the June 2019 remand, has the exact same problem. The examiner gave the following opinion on secondary service connection: Diabetes has not been established as a risk factor for pancreatic cancer. Although epidemiologic studies describe an association between pancreatic cancer and diabetes mellitus there are competing theories to explain this association. One model suggests an etiologic relationship whereby diabetes mellitus causes pancreatic cancer. Other models suggest diabetes may be a consequence rather than a cause of pancreatic cancer. There is evidence supporting both of these models and there is no current consensus regarding which model best explains the observed association... Thus diabetes mellitus has not been established as a risk factor for pancreatic cancer. Once again, the opinion broadly discusses conflicting medical literature on whether diabetes causes pancreatic cancer, or pancreatic cancer causes diabetes, and fails to mention facts that may make one explanation less likely than the other in this particular case. If an opinion is going to rely, in part, on a conclusion that the Veteran's diabetes may have been caused by his pancreatic cancer, the examiner must explain how the Veteran's pancreatic cancer was not diagnosed until 13 years after his diabetes diagnosis. When a case is remanded, a veteran is entitled to substantial compliance with all remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). If the RO does not substantially comply with the Board's remand instructions, the Board is legally bound to continue remanding until the mistake is corrected. See id. Furthermore, when VA provides an examination, it has a duty to ensure that the examination is adequate, Barr v. Nicholson, 21 Vet. App. 303, 312 (2007), and based on a full consideration of the Veteran's complete medical history, Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). A second remand is required to obtain a VA medical opinion that meets these requirements. The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate physician regarding the etiology of the Veteran's pancreatic cancer. The entire claims file, including a copy of this remand, should be made available to the examiner for review. Once the examiner certifies that they have reviewed the full claims file, they shall answer the following questions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's pancreatic cancer is related to any event, injury, or disease incurred during active service, to include exposure to herbicide agents? (b) Is it at least as likely as not that the Veteran's pancreatic cancer was caused or aggravated by a service-connected disability, to include diabetes mellitus, type II? The examiner must discuss the relationship between diabetes mellitus, type II and the development of pancreatic cancer in the context of the Veteran's medical history. The examiner must not only discuss the medical literature which suggests a relationship between diabetes and pancreatic cancer, but also take into account the fact that the Veteran's diabetes appears to predate the onset of his pancreatic cancer by 13 years. (c) If the Veteran's pancreatic cancer is unrelated to his active duty service or any service-connected disability, what is its likely etiology? A complete and fully explanatory rationale must be provided for any opinion offered, citing any record evidence or medical literature relied upon. If an opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.