Citation Nr: 22013785 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 18-28 511 DATE: March 10, 2022 REMANDED Entitlement to service connection for a skin condition, to include basal cell carcinoma and actinic keratosis, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1965 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2021 the Board remanded the matter for a medical examination and opinion. Unfortunately, the Board finds that further remand is required in order to ensure the Veteran is provided with an adequate etiology opinion. As directed by the Board's prior November 2021 decision, a C&P examination was provided in December 2021 to assess the Veteran's skin diseases as well as residual scars from surgery for basal cell carcinomas, and to opine on any relation to service, to include exposure to herbicide agents and to UVB rays. Regarding the Veteran's claim that his basal cell carcinoma was caused by his in-service exposure to herbicide agents, the C&P examiner stated that she "found no peer reviewed research literature to support the opinions or hypothesis of Agent Orange causing his . . . skin conditions." The examiner acknowledged the May 2018 private opinion from Dr. S.R., which stated that "Basal Cell Carcinoma . . . has been associated with herbicide Agent Orange" and cited to an untitled article from the October 1990 issue of the Journal of the American Medical Association (JAMA); the C&P examiner remarked, however, that the article referenced by Dr. S.R., "An Interpretation of Michelangelo's Creation of Adam Based on Neuroanatomy," did not appear to be a peer-reviewed research article. The October 1990 issue of JAMA, however, included an article preceding the one found by the C&P examiner, titled "Health Status of Air Force Veterans Occupationally Exposed to Herbicides in Vietnam," and this article conducted a statistical analysis that found a group of veterans exposed to herbicide agents in Vietnam "experienced significantly more basal cell carcinomas than comparison subjects" not exposed to herbicide agents. Moreover, the JAMA Network states on its website that it is a peer-reviewed journal. About JAMA Network Open, available at https://jamanetwork.com/journals/jamanetworkopen/pages/for-authors#fa-about (last accessed March 2022). Accordingly, as the evidence reflects the article cited by Dr. S.R. is "peer reviewed research literature to support the opinions or hypothesis of Agent Orange causing" basal cell carcinoma, the Board finds that remand is required for the examiner to address this evidence. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Additionally, regarding a potential connection between the Veteran's skin conditions and UVB exposure, the December 2021 C&P examiner stated that the Veteran's "record is silent for complaints of sunburn or other evidence of excessive USB exposure during service." The Veteran has submitted, however, an article from SkinCancer.org stating that a diagnosis of actinic keratoses, with which the Veteran was previously diagnosed, "indicates that you have sustained sun damage and could develop any kind of skin cancer," and in Dr. S.R.'s May 2018 letter it was stated that the Veteran had "significant UVB exposure during his tour of duty in Vietnam." On remand the examiner will also be directed to address this evidence that the Veteran may have had significant UVB exposure resulting in sun damage during his service. Id. Finally, regarding actinic keratoses, the December 2021 examiner noted that while the Veteran had historically been treated for actinic keratosis and basal cell carcinoma, he did not currently have visible lesions or treatment in over a year for either of the conditions. While the Board acknowledges this finding that actinic keratosis was not present in December 2021, VA treatment records reflect that the Veteran had an active diagnosis of actinic keratosis (for example, at a VA dermatology visit in November 2018) since the time of his July 2017 claim for service connection. Therefore, an opinion should be provided whether the Veteran's actinic keratosis at that time was related to his service. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement for a current disability is satisfied where the evidence shows the Veteran had a disability at any time during the pendency of his claim). Accordingly, the matter is REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the Veteran's basal cell carcinoma (with current residual scars from surgical treatment) and actinic keratoses. It is the clinician's discretion whether a new examination is needed. The clinician must opine on all of the following: (a) Is the Veteran's basal cell carcinoma with residual scars at least as likely as not due to his exposure to Agent Orange during service? Consider and discuss (i) a May 2018 opinion letter from Dr. S.R. that "it is reasonable to hypothesize that [the Veteran']s basal cell carcinoma skin cancers are highly likely associated to his exposures in Vietnam" to include his exposure to Agent Orange; (ii) the peer-reviewed article "Health Status of Air Force Veterans Occupationally Exposed to Herbicides in Vietnam" (published in the October 1990 issue of JAMA), which conducted a statistical analysis that found a group of veterans exposed to herbicide agents in Vietnam "experienced significantly more basal cell carcinomas than comparison subjects" not exposed to herbicide agents; and, (iii) an undated opinion letter from Dr. S.I. (uploaded into the virtual record 9/6/2018) stating that the Veteran "ha[s] more cancers on the face than one would expect given his age and history" and opining that "it may very well be possible that his skin cancers are related to his Agent Orange exposure in the past." (b) Is the Veteran's basal cell carcinoma with residual scars at least as likely as not due to his exposure to UVB rays during service? Consider (i) Dr. S.R.'s May 2018 letter stating that the Veteran had "significant UVB exposure during his tour of duty in Vietnam" and concluding that "it is reasonable to hypothesize that his basal cell carcinoma skin cancers are highly likely associated to his exposures in Vietnam" to include the UVB exposure; and, (ii) a SkinCancer.org article stating that a diagnosis of actinic keratoses (which the Veteran has been diagnosed with) "indicates that you have sustained sun damage and could develop any kind of skin cancer." (c) Is the Veteran's basal cell carcinoma with residual scars at least as likely as not due to his combined exposure to herbicide agents and to UVB rays during service? Consider and discuss Dr. S.R.'s May 2018 conclusion that "it is reasonable to hypothesize that [the Veteran']s basal cell carcinoma skin cancers are highly likely associated to his exposures in Vietnam." (d) Is the Veteran's formerly diagnosed actinic keratoses (to include an active diagnosis at a November 2018 VA dermatology visit) at least as likely as not related to his service? Consider and discuss (i) the SkinCancer.org article stating that a diagnosis of actinic keratoses "indicates that you have sustained sun damage and could develop any kind of skin cancer" and (ii) the statement in Dr. S.R.'s May 2018 letter that the Veteran had "significant UVB exposure during his tour of duty in Vietnam." K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Davis, 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.