Citation Nr: 22018058 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 14-38 964 DATE: March 28, 2022 REMANDED Service connection for breast cancer is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1990 to December 1994. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). The case was previously before the Board in May 2018, October 2019, and June 2021, at which time the Board remanded the case for additional development. The case returns to the Board at this time for further appellate review. As an initial matter, this appeal originally included a claim of service connection for anemia. In a November 2021 rating decision, the RO granted the Veteran service connection for anemia with a noncompensable (0 percent) evaluation, September 16, 2011. This constituted a full grant of the benefits sought on appeal for that issue. Thus, the claim of service connection for anemia is no longer on appeal before the Board. Service Connection for Breast Cancer While the Board sincerely regrets further delay in this matter, there has not been substantial compliance with the June 2021 remand directives. Consequently, another remand is required under the law. In the June 2021 Board decision, the Board acknowledged the April 2021 Written Presentation Brief where the Veteran's representative cited to articles suggesting an etiological relationship between the Veteran's breast cancer and her use of oral contraceptives in active service. The Board remanded the issue for a new VA medical opinion. The Board requested that the VA examiner discuss the medical articles cited by the Veteran's representative in the April 2021 Written Presentation Brief. The Board also noted that the Veteran had a recent reoccurrence of triple negative breast cancer, and the Board requested that the VA examiner also address the significance, if any, of the Veteran's recent recurrence of triple-negative breast cancer. In an October 2021 VA medical opinion, the VA examiner found that the Veteran's claimed breast cancer was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Specifically, the VA examiner found that the Veteran's breast cancer is less likely than not related to use of oral contraceptives in service. The VA examiner stated that the STRs indicate that the Veteran requested use of oral contraceptives during service and was initially prescribed them in September 1991. The Veteran left active service in December 1994 and continued to use OCP's until 1998. The VA examiner explained that, although there is an increased risk in developing breast cancer from OCP use and no other risk factors have been identified to increase a risk for breast cancer, the Veteran's OCP use was not solely during service and therefore the breast cancer is not only due to the Veteran's use of OCP in service. However, the Board notes that VA service connection does not require that an in-service cause of a disorder be the sole or only cause. For example, if the Veteran's in-service use of contraceptives played any distinct part in causing the Veteran's breast cancer, then such disorder may qualify for service connection. Here, it is still unclear from the medical nexus opinions of record, including the October 2021 VA medical opinion, whether the Veteran's in-service use of contraceptives caused or aggravated the Veteran's breast cancer. Additionally, the October 2021 VA examiner did not discuss the articles cited by the Veteran's representative in the April 2021 Written Presentation Brief as the Board had requested in the June 2021 Board decision. The Board notes that, pursuant to the June 2021 Board remand, the October 2021 VA examiner also provided an opinion concerning whether the Veteran's breast cancer was secondary to her service-connected endometriosis. The Board finds that the October 2021 VA examiner's opinion on secondary service connection substantially complied with the June 2021 Board remand. The matter is REMANDED for the following action: Forward the record, to include a copy of this Remand, to an appropriate VA examiner to obtain a new medical opinion concerning the nature and etiology of her claimed breast cancer. After review of the evidence, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's breast cancer was incurred in, caused by, aggravated by, or otherwise related to her active service, including but not limited to her use of oral contraceptives during active service. In providing this opinion, the examiner should discuss the online medical articles cited by the Veteran's representative in the April 2021 Written Presentation Brief. The examiner is also requested to address the significance, if any, of the Veteran's recent recurrence of breast cancer. The examiner should also note that VA service connection does not require that an in-service cause of a claimed disorder be the sole or only cause. If the Veteran's in-service use of oral contraceptives played any notable part in causing the Veteran's breast cancer, then such disorder may qualify for service connection. The examiner should consider any other pertinent evidence of record, as appropriate. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If the examiner determines that a requested opinion cannot be rendered without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general knowledge of the medical community at large (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). (Continued on the next page) All findings by the examiner should be reported in detail, and all opinions must be accompanied by a clear and complete rationale. R.R. WATKINS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, 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.