Citation Nr: A25035112 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 210302-525431 DATE: April 16, 2025 ORDER Entitlement to service connection for pancreatic cancer is granted. FINDING OF FACT The evidence is in at least a state of approximate balance as to whether the Veteran's pancreatic cancer was incurred in service. CONCLUSION OF LAW The criteria for service connection for pancreatic cancer are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from June 1974 to July 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). Procedurally, the Veteran initially filed his claim for service connection for pancreatic cancer in December 2020. See December 2020 Application for Disability Compensation and Related Compensation Benefits (VA Form 21-526EZ). The claim was denied in a January 2021 decision. See January 2021 Rating Decision. The Veteran requested Higher Level Review of this decision, and in a decision dated later that month, a higher-level reviewer at the RO continued to deny service connection for pancreatic cancer. See January 2021 Decision Review Request: Higher-Level Review (VA Form 20-0996); January 2021 Rating Decision. Thereafter, in March 2021, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) and elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the January 2021 agency of original jurisdiction (AOJ) decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the March 2021 VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. Unfortunately, the Veteran died in August 2021, while his appeal was pending. The Veteran's spouse was found to be a substitute party for the purpose of continuing to pursue the Veteran's claims on appeal after his death. See August 2023 Notification Letter (notifying the appellant that she met the basic eligibility for substitution). Accordingly, the appellant has been substituted as the claimant for the purposes of processing the Veteran's claim to completion. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In addition, certain chronic diseases, including malignant tumors (cancer), will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). 1. Entitlement to service connection for pancreatic cancer is granted. The Veteran has asserted entitlement to service connection for pancreatic cancer, maintaining that the condition was caused by his in-service exposure to Aqueous Film-Forming Foam (AFFF) and other chemicals during the performance of his "firefighting and shipboard damage control duties." See December 2020 VA Form 21-526EZ. As an initial matter, the Board notes that the AOJ recognized that the Veteran was diagnosed with pancreatic cancer and further conceded in-service exposure to AFFF during his active service during the performance of his duties as an Aviation Boatswain's Mate. See January 2021 Rating Decision. Accordingly, the first and second elements of service connection, namely that of a current disability and incurrence of an in-service injury, are established. See 38 C.F.R. § 3.104(c) (reflecting that favorable findings made by VA adjudicators are binding on all subsequent VA adjudicators, absent clear and unmistakable error). Therefore, the question remains whether there is evidence of a nexus between the diagnosed pancreatic cancer and the Veteran's in-service exposures. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). In this regard, there is medical evidence of record linking the Veteran's diagnosed pancreatic cancer to his active service. Specifically, in a December 2020 letter, T.T., PA-C, MPAS, opined that it was "more likely than not that Veteran['s] pancreatic cancer [wa]s due to his exposure to AFFF foam while participating in firefighting training over his 30-year career in service." See December 2020 Correspondence from T.T., PA-C, MPAS. T.T. explained that "medical literature and all professional national and international organizations on health and occupational materials have concluded that these chemicals are associated with an increased risk of cancers," including specifically pancreatic cancer. See id. Additionally, the Veteran did not otherwise "have an exposure greater than the general public in nonproblematic areas," and did not "have any other risk factor to have caused this condition" aside from his exposure to the Perfluoroalkyl and Polyfluoroalkyl Substances (PFAS) contained in AFFF. Id. This opinion represents the informed conclusions of a medical professional with relevant expertise; reflects a thorough understanding of the Veteran's service records, medical records, and clinical history; is supported by thorough, clear, well-reasoned explanations with citations to the evidence of record and references to relevant medical principles, treatises, and studies; and is generally consistent with the evidence of record, including the Veteran's service records, medical treatment records, and submissions. As such, T.T.'s December 2020 opinion constitutes highly probative evidence weighing in favor of a relationship between the Veteran's diagnosed pancreatic cancer and his active service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion depends upon whether it is factually accurate, fully articulated, and contains sound reasoning for the conclusion); Prejean v. West, 13 Vet. App. 444, 448 (2000) (holding that the Board may determine the probative value of medical opinions based on their detail and persuasiveness, and the physicians' access to a Veteran's medical records). The Board acknowledges that there is opinion evidence to the contrary in the form of the December 2020 VA medical opinion finding that the Veteran's pancreatic cancer was unrelated to his in-service AFFF exposure. See December 2020 VA Gallbladder and Pancreas Conditions Disability Benefits Questionnaire (DBQ). However, the December 2020 VA opinion does not sufficiently outweigh the medical opinion submitted by the Veteran in support of his claim. In this regard, although the VA examiner found against a relationship between the Veteran's pancreatic cancer and his service, the opinion does not explain which, if any, of the other known risk factors for the development of pancreatic cancer pertained to the Veteran or were a more likely the cause of his pancreatic cancer than his in-service chemical exposure. See id. Accordingly, viewing the evidence in the light most favorable to the Veteran, and considering the probative medical opinion evidence linking the Veteran's pancreatic cancer to his active service, the Board finds that, at the least, reasonable doubt exists as to the question of the origin of the Veteran's pancreatic cancer. When resolving reasonable doubt in favor of the Veteran, the Board finds that there is at least an approximate balance of positive and negative evidence with respect to the question of whether the Veteran's pancreatic cancer is attributable to his active military service. Under VA law, in such a circumstance, the claimant must prevail. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). As such, service connection for pancreatic cancer is granted. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. McCabe, 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.