N4NW

I am trying to find information on how to link Pleomorphic Adenoma and agent orange. Specifically, I am seeking a document produced by the VA iand used to render a decision in a case adjudicated by the VBA 6/24/2013. How do I obtain a copy of this original VHA's expert report? In that decision the VA stated: "The Veteran claims that his adenocarcinoma of the left parotid gland resulted from exposure to herbicides during his service in Vietnam. The Veteran's service records document that he served in Vietnam during the Vietnam Era, and his exposure to herbicides is presumed." Further, the VA states: "In January 2013, the Board sought the medical opinion of a VHA medical expert to address the medical questions raised in this case concerning the etiology of the Veteran's adenocarcinoma. A March 2013 VHA expert medical advisory opinion thoroughly addresses this matter with discussion of relevant medical principles, reference materials (some of which were included with the report), and the pertinent facts of this case. The author of the March 2013 VHA expert medical opinion also attached pertinent reference material concerning the subject matter as well as details of the author's own substantial expertise in matters of molecular biology. The Board finds that the March 2013 VHA expert opinion is very probative evidence in this case. The March 2013 VHA expert medical opinion explains that salivary gland cancers are quite rare and details, with statistical information, the difficulty in assigning risk factors for parotid tumors in light of their relatively infrequent occurrence. The VHA expert explains that "[t]he etiology of salivary gland cancers remains undetermined." He notes that two known major risk factors are exposure to ionizing radiation "which accounts for 10-30% of these malignancies" and having had a prior cancer. Other noted risk factors include age, exposure to ultraviolet radiation, and occupational exposure to certain materials involved in "rubber manufacturing, asbestos mining, and plumbing." The expert also notes that heavy alcohol consumption and current smoking constitute risk factors in men. The VHA expert acknowledges that tactical herbicide agents (such as Agent Orange) are not among the currently established risk factors for the form of cancer at issue. However, his discussion indicates that it is nevertheless reasonable to consider Agent Orange capable of causing the Veteran's form of cancer; the VHA advisory opinion emphasizes that the extent of confirmed medical knowledge on this form of cancer remains notably limited. The March 2013 VHA expert advisory opinion explains: "In general, cancers are caused by mutations, particularly those in DNA. As Agent Orange is known to be mutagenic, then by extension, it could be responsible for mutations which cause salivary gland cancers." The expert goes on to state that "it would be difficult to establish or disprove any contribution of Agent Orange exposure to parotid gland tumors," and explains that such a determination would be difficult for reasons including the relatively small number of salivary gland cancers in the general population and the relatively high proportion of observed cases that have been attributed to ionizing radiation. The expert further explains that the etiological links between certain mutagens and specific cancers may be determined with reference to associated mutations in specific sequences of DNA linked with specific cancers, but there remains a lack of knowledge in medical science concerning the potential of mutagens to alter other key bio-genetic features (to alter specific sequences of RNA, micoRNAs, or DNA conformation, etc)." and, "The VHA expert's report goes on to additionally explain that "[s]alivary gland cancers could be considered a class of head and neck cancers. Head and neck cancers have been attributed to Agent Orange." The expert reasons: "Then by extension, parotid and other salivary gland cancers could theoretically arise from mutations attributable to Agent Orange exposure." The expert acknowledges that "[a]t the present time, the American Cancer Society classifies the evidence for a relationship between Agent Orange and mouth, throat, and nose cancers (head and neck cancers) as inadequate/insufficient." The expert's acknowledgement of this information strongly suggests that it was contemplated in the key assertions presented in the advisory opinion: (1) that there is a reasonable medical basis for considering exposure to Agent Orange to be capable of causing adenocarcinoma of the left parotid gland, and (2) that there is evidence that head and neck cancers such as the Veteran's can be attributed to Agent Orange. Nothing in the VHA expert's advisory opinion suggests that the American Cancer Society's classification should be interpreted as foreclosing consideration of Agent Orange as a cause of the Veteran's adenocarcinoma of the left parotid gland. Finally, the VHA expert acknowledges that the parotid malignancy did not manifest until 2008, and asserts that this "does not negate the possibility of a relationship between Agent Orange exposure and his malignancy. There is a latency period for almost all cancers...." The VHA expert opinion suggests that it is medically reasonable to regard Agent Orange as a significant candidate for causing the adenocarcinoma of the left parotid gland. Although the expert explains that Agent Orange is not among the research-established significant risk factors for this specific cancer, the Board finds significant the expert's emphasis regarding the limitations of the state of medical research and knowledge as to the etiological profile of this particular form of cancer. Although the current state of medical research has not identified Agent Orange as a recognized potential cause of the form of cancer at issue, it appears that the VHA expert nonetheless considers Agent Orange a plausible etiological factor for the left parotid gland adenocarcinoma. The expert explains the basis for considering Agent Orange a plausible potential cause, and further explains that the established general etiological profile that omits Agent Orange is substantially limited and incomplete due to the rarity of instances of this particular form of cancer. The VHA expert appears to consider the current state of medical research on this form of cancer to be inadequately developed to compellingly discount his own impression that the mutagenic capacity of Agent Orange can cause left parotid gland adenocarcinoma. The Board finds the explanation persuasive. Acknowledging that Agent Orange is not an established risk factor for the Veteran's left parotid gland adenocarcinoma, the VHA expert explains that the mutagenic properties of Agent Orange could cause such salivary cancer; his discussion does not reflect that there is any compelling medical reason to reject Agent Orange as a potential cause for such cancer. The Board interprets the VHA expert's opinion as presenting a reasonable basis for linking the Veteran's left parotid gland adenocarcinoma to Agent Orange exposure (with additional explanation that such a link cannot more definitively be proved or disproved). The VHA expert's advisory opinion thus indicates that exposure to Agent Orange is a possible cause of the cancer at issue, and does not identify any more probable etiology for the cancer. The expert notes the Veteran's history of tobacco smoking, but does not indicate that it is a more likely etiological factor for the left parotid gland adenocarcinoma. The Board finds that the expert's opinion does not merely leave the matter to speculation; the expert explains in detail, and without contradiction, that it is reasonable to consider the mutagenic properties of Agent Orange capable of causing left parotid gland adenocarcinoma. The expert explains this in terms including principles of molecular biology. That Agent Orange has not been linked to this form of cancer by existing medical research may weigh against the Veteran's claim, but such is mitigated by the VHA expert's explanation of the limitations of current medical knowledge concerning the etiological profile of this rare cancer. The absence of an established link in current research, in this case involving a rare cancer with a poorly understood etiological profile, does not outweigh the VHA expert's explanation of the molecular-biological reasonableness of linking the claimed cancer to Agent Orange's mutagenic properties. On longitudinal review of the record, the Board finds that the evidence reasonably supports the Veteran's claim that his adenocarcinoma of the left parotid gland is causally related to his exposure to Agent Orange or other tactical herbicide agents in-service. His exposure to herbicides in Vietnam is presumed. The highly probative March 2013 VHA expert advisory opinion establishes that such exposure may reasonably be considered an etiological factor for the left parotid gland adenocarcinoma at issue. The most significant negative evidence in this case is the absence of medical research establishing Agent Orange as a recognized risk factor of this specific form of cancer. The March 2013 VHA expert advisory opinion is highly probative as to why it is medically reasonable to consider exposure to tactical herbicides a cause of the left parotid gland adenocarcinoma.