Citation Nr: 22046367 Decision Date: 08/16/22 Archive Date: 08/16/22 DOCKET NO. 15-35 180 DATE: August 16, 2022 REMANDED Entitlement to service connection for colon and/or rectal cancer, to include lymphoma (previously claimed as cancer of the lymph nodes), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1967 to December 1970, including service in the Republic of Vietnam (Vietnam). This matter previously came before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued July 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter August 2018. In August 2020, the Veteran requested a hearing, which was held in June 2022. A transcript of the hearing is associated with the record, and the Board will proceed with appellate review accordingly 1. Entitlement to service connection for colon and/or rectal cancer, to include lymphoma (previously claimed as cancer of the lymph nodes, is remanded. The Veteran claims entitlement to service connection for colon and/or rectal cancer, to include lymphoma (previously claimed as cancer of the lymph nodes) (hereinafter referred to as "Adenocarcinoma"). Specifically, the Veteran contends that his Adenocarcinoma is caused by his in-service exposure to herbicides, including Agent Orange. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a) and (d). In order to establish service connection, the claimant must show the existence of a present disability, an in-service incurrence or aggravation of a disease or injury, and a causal relationship or "nexus" between the present disability and the in-service injury or disease. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). An August 2019 medical opinion stated that the Veteran has Adenocarcinoma. Thus, the Veteran has a current disability. In addition, the Veteran had service in Vietnam, therefore, exposure to herbicides, including Agent Orange, is conceded. The remaining inquiry is whether there is a nexus, or link, between the Veteran's in-service herbicide exposure and his Adenocarcinoma. VA has a duty to assist a claimant in "providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim." 38 U.S.C. § 5103A(d)(1). Once the Secretary undertakes the effort to provide an examination, he must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). "A medical opinion is adequate when it is based upon consideration of the [V]eteran's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Id. at 310-11 (internal quotations omitted) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). As such, the medical examiner must be aware of the Veteran's relevant medical history, and they must provide a clear conclusion, supported by a reasoned medical explanation connecting the examiner's conclusion to supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, the Veteran was provided with a VA examination and medical opinion in March 2019 and August 2019. However, the August 2019 opinion is inadequate because the examiner failed to provide a well-reasoned rationale. See Id. at 301. Specifically, while the VA examiner acknowledged the Veteran's in-service exposure to herbicides and noted his diagnosis of Adenocarcinoma with lymph node metastasis, the examiner stated that it is unlikely that the Veteran's "neoplasia" is related to his military service and concluded that it is less likely than not "that colon cancer" is related to the Veteran's military service, to include exposure to herbicides. The rationale provided for this determination was that "[t]his type of cancer is not presumptive related to exposure to herbicides" and that it is a common type of cancer in individuals over the age of 50. Although the Adenocarcinoma is not an enumerated presumptive condition based on exposure to herbicides, including Agent Orange, the Board must address whether direct service connection based on exposure to Agent Orange is warranted. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994); Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). A medical opinion which concludes that a disease is not related to herbicide exposure solely because there is no presumption of service connection (i.e., is not listed in 38 C.F.R. § 3.309) is inadequate. Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009). A clinician cannot conclude that a disability cannot be associated with herbicide exposure simply because it is not on the list of presumptive service-connected diseases. Accordingly, remand is required to obtain an addendum opinion regarding whether the Veteran's Adenocarcinoma is related to his presumed exposure to herbicides in service. See Barr, 21 Vet. App. at 311. In accordance with the above, the matter is REMANDED for the following action: 1. With any necessary identification of sources and authorization by the Veteran, request all private treatment records from the Veteran not already associated with the file, to include treatment records for lymphoma. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran's claims file. 2. Obtain an addendum VA opinion addressing the etiology of the Veteran's Adenocarcinoma. The entire claims file should be made available to the examiner for review. An examination is not necessary unless the examiner deems it so. The examiner is asked to provide a response to the following: What is the likelihood that the Veteran's exposure to herbicides, including Agent Orange, played a role in the development of his Adenocarcinoma? The examiner should consider the Veteran's specific facts and circumstances, including that he had exposure to herbicides, as well as the fact that the Veteran has no family history of Adenocarcinoma, nor did he have other significant risk factors that would predispose him to this type of cancer, such as smoking the Veteran was a non-smoker. In answering this question, the VA examiner must explain in clinical terms with substantiation from medical treatise evidence or clinical studies or other citations, the relative weight of risk factors, to include known information about the Veteran's case. The examiner is advised that the mere fact that presumptive service connection has not been established by VA for Adenocarcinoma after herbicide exposure is not dispositive of the issue of a nexus to service. The VA examiner must analyze the likelihood that the Veteran's Adenocarcinoma is a direct result of his herbicide exposure. If any opinion requested above 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 medical knowledge (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). TRACIE N. WESNER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wolfe, Leta A. 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.