Citation Nr: 23023402 Decision Date: 04/21/23 Archive Date: 04/21/23 DOCKET NO. 19-12 826 DATE: April 21, 2023 ORDER Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for erectile dysfunction (ED) as secondary to prostate cancer is denied. FINDINGS OF FACT 1. The Veteran's prostate cancer is not causally or etiologically related to service, to include exposure to contaminated water at Camp Lejeune, and did not manifest within one year of separation from active duty. 2. The Veteran's ED is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for prostate cancer have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1971 to March 1975. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision issued by a Department of Veteran Affairs (VA) Regional Office. 1. Entitlement to service connection for prostate cancer, to include as due to exposure to contaminated water at Camp Lejeune. The Veteran contends his prostate cancer is related to his military service. Specifically, he contends it is due to his exposure to contaminated water while serving at Camp Lejeune. Direct service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, the three-element test for service connection requires: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Veterans, reservists, or members of the National Guard who served no less than 30 days at Camp Lejeune during the period from August 1, 1953, to December 31, 1987, shall be presumed to be exposed to contaminated water. 38 C.F.R. § 3.307(a)(7). The Veteran's requisite service at Camp Lejeune has been established from February 5, 1972, to March 18, 1972. Thus, the Veteran is presumed to have been exposed to contaminated water. Prostate cancer is not listed among the diseases that are caused by exposure to contaminants in the water supply systems at Camp Lejeune, as defined by the regulation. See 38 C.F.R. § 3.309(f). Therefore, the Board finds presumptive service connection on this basis is not applicable. Prostate cancer, as a form of malignant tumor, may also be presumed related to service as a chronic disease. 38 C.F.R. § 3.309(a). However, this presumption requires in-service manifestations either sufficient to identify the disease in-service, symptoms continuously since service, or manifestations to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.303(b), 3.307(a). The evidence of record indicates that the Veteran's prostate cancer was not present until approximately decades after his separation from service, and he does not contend otherwise. Thus, presumptive service connection is not available for prostate cancer as a chronic disease. Id. Nevertheless, service connection for a disability claimed as due to contaminated water at Camp Lejeune may be established directly by showing that a disorder resulting in disability was in fact causally linked to such exposure. See Combee v. Brown, 34 F. 3d 1039, 1044 (Fed. Cir. 1994). Thus, the remaining question for the Board is whether the Veteran's prostate cancer is causally related to his service, to include his presumed exposure to contaminated water. The Veteran was diagnosed with prostate cancer in 2013. The Veteran's prostate cancer is currently active, and therefore, the Board finds the first element for service connection is met. The Veteran's service treatment records are silent for any complaints or treatment for prostate cancer or its accompanying symptoms. Likewise, his entrance and exit examinations are silent for diagnoses related to prostate cancer. In February 2015, the Veteran submitted private medical treatment records for his prostate cancer. The Board notes these records confirm the Veteran's diagnosis and treatment of prostate cancer, but there is no medical opinion regarding the etiology of such therein. As such, the evidence is relevant but is not afforded probative weight with respect to the nexus element. In July 2015, a VA medical opinion was obtained to determine the nature and etiology of the Veteran's prostate cancer. The clinician opined the Veteran's prostate cancer was less likely than not caused by exposure to contaminated water at Camp Lejeune. The clinician supported the rationale by citing to the American Cancer Society, which notes that after skin cancer, prostate cancer is the most common cancer in American men and that "prostate cancer rarely occurs before the age of forty, but the incidence rises rapidly thereafter." With respect to the Veteran's circumstances of serving at Camp Lejeune and being exposed to contaminated water, the clinician cited to a study regarding the effects of the contaminated drinking water were evaluated and demonstrated no elevated risk of prostate cancer. The clinician also noted that in response to concerns about cancer stemming from drinking water contaminated with PCE and TCE, a Morgan et al. 2002 study and review did not observe an overall cancer excess. The clinician noted this study showed the standardized incidence ratio for prostate cancer was 1.11, which was not statistically significant. With regard to occupational exposure and the risk of developing prostate cancer, the clinician explained that "even within the occupationally exposed workers, those researchers that have looked at the question have concluded that only the highest levels of exposure are associated with a potentially increased risk for the development of prostate cancer." The clinician further cited to an NAS review, which summarized three studies and found a small excess risk in individuals with high exposures in those with more than five years of occupational exposure and that individuals with occupational exposure to TCE had between a 1.0 and 1.3 fold risk of developing prostate cancer. The clinician also noted a Radican study, which found no increased incidence of prostate cancer in workers exposed to TCE. The clinician explained that in a Hansen et al. published report, the study's population was exposed to greater TCE levels compared with what would have reasonably occurred at Camp Lejeune, and for prostate cancer, the SIR (standard incidence ration) was .96, which is not statistically significant. Although some occupational studies noted substantial occupational exposure for at least five years, which show there may be an increased risk of developing prostate cancer, there are many other studies that have found no increase in risk after workplace exposure. In the instant case, because the Veteran's exposure to Camp Lejeune was only 43 days, such decreased the link between chemical exposure and the development of prostate cancer; additionally, the Veteran was diagnosed at age 60, and due to his risk factors of age and obesity, which are much greater risk factors for the development of prostate cancer, the clinician opined it is less likely than not the Veteran's prostate cancer was caused by his exposure to contaminated water at Camp Lejeune. The Board notes the clinician supported the rationale with citations to twenty-two medical peer-reviewed articles on this matter. In a May 2019 VA Form 9, the Veteran cited a VA letter dated November 29, 2011, indicating that prostate cancer is a possible condition due to exposure to TCE. While prostate cancer is listed as a possible condition due to the exposure of TCE, the Board notes this VA letter does not state it is a conclusive outcome. Here, the letter does not suggest a generic relationship between his prostate cancer and in-service exposure to contaminated water with a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts. Consequently, such is insufficient to establish service connection for the Veteran's prostate cancer. Wallin v. West, 11 Vet. App. 509 (1998); Sacks v. West, 11 Vet. App. 314 (1998); Libertine v. Brown, 9 Vet. App. 521 (1996). Conversely, the Board affords great probative value to the VA clinician's opinion as such reflects consideration of all relevant facts, with specific consideration of the Veteran's service circumstances and medical history, and is supported by a complete rationale, relying on and citing to the records reviewed and outside medical literature. Moreover, the clinician offered a clear conclusion with supporting data as well as a reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In so finding, the Board notes the Veteran's contention that "any reasonable person would find that being exposed to carcinogen for only 43 days would not and should not determine whether the contaminated water at Camp Lejeune caused his prostate cancer." See June 2016, Notice of Disagreement (NOD). In this regard, while the length of time the Veteran was stationed at Camp Lejeune was a factor taken into consideration by the July 2015 VA examiner, such clearly was not the sole factor in making the determination. Additionally, the Board acknowledges the Veteran's lay testimony as to the etiology of his prostate cancer. However, while he is competent to report certain symptoms, the Board finds that he is not competent to offer an opinion as to whether his prostate cancer is related to any instance of his service, to include exposure to contaminated water, since he does not possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorder, to include whether such is related to his in-service exposure that occurred decades previously, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran, as a lay person, is not competent to offer an opinion, and, consequently, his opinion on such matter is afforded no probative weight. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In conclusion, the Board finds that the Veteran's prostate cancer is not causally or etiologically related to service, to include his presumed exposure to contaminants in the water supply at Camp Lejeune. As the persuasive evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim of entitlement to service connection for prostate cancer must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for ED as secondary to prostate cancer. In the instant case, the Veteran has advanced the narrow theory of entitlement to service connection for ED as secondary to his prostate cancer. Robinson v. Shinseki, 557 F.3d 1355 (2008). In pertinent part, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). A November 2014 Prostate Cancer Disability Benefits Questionnaire (DBQ) reflects a diagnosis of ED, with an onset of October 2013. The Board notes that the term "organic impotence" has been used interchangeably for ED in his private medical records. See VBMS, document labeled Medical Treatment Record- Non-government facility, receipt date 2/2/15. To avoid confusion and uncertainty, the Board will use ED in its discussion. In response to the Veteran's specific assertions, however, the Board finds determinative that he is not in receipt of service connection for prostate cancer. The Board herein denies service connection for prostate cancer. Thus, service connection for ED as secondary to such disorder is not a viable theory of entitlement. Further, the probative evidence does not show the Veteran's current ED is caused or aggravated by a disability for which VA has awarded service connection. Rather, the private physician who completed the aforementioned November 2014 DBQ noted ED was an additional diagnosis that pertains to prostate cancer, and the remainder of the medical evidence does not support a finding otherwise. Here, the Veteran is only in receipt of service connection for bilateral hearing loss and tinnitus, and the evidence, to include the Veteran's own lay statements, does not support a nexus between ED and either disability. (Continued on the next page) ? In sum, the Board finds ED is not shown to be caused or aggravated by a service-connected disability. Consequently, service connection for such disorder is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the probative evidence persuasively weighs against the Veteran's claim of entitlement to service connection for erectile dysfunction as secondary to prostate cancer. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Smith 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.