Citation Nr: 23012788 Decision Date: 03/02/23 Archive Date: 03/02/23 DOCKET NO. 18-38 164 DATE: March 2, 2023 ORDER Service connection for metastatic embryonal cell carcinoma of the left testicle is granted. Service connection for retroperitoneal carcinoma secondary to metastatic embryonal cell carcinoma of the left testicle is granted. Service connection for erectile dysfunction (ED) secondary to metastatic embryonal cell carcinoma of the left testicle is granted. Special monthly compensation (SMC) based on loss of use of a creative organ is granted. Service connection for stage 4 undifferentiated metastatic carcinoma secondary to service-connected embryonal cell carcinoma of the left testicle is granted. Service connection for lumbar spine neoplasm secondary to metastatic embryonal cell carcinoma of the left testicle is granted. Service connection for lung neoplasm secondary to metastatic embryonal cell carcinoma of the left testicle is granted. Service connection for brain neoplasm secondary to metastatic embryonal cell carcinoma of the left testicle is granted. Service connection for lumbar vertebral fracture at L3 secondary to lumbar spine neoplasm is granted. Service connection for nerve damage of the lumbar spine secondary to lumbar spine neoplasm is granted. Service connection for muscle strain and weakness of the back and legs secondary to lumbar spine neoplasm is granted. Service connection for peripheral neuropathy of the right lower extremity secondary to stage 4 undifferentiated metastatic carcinoma is granted. Service connection for peripheral neuropathy of the left lower extremity secondary to stage 4 undifferentiated metastatic carcinoma is granted. Service connection for cognitive disorder not otherwise specified (NOS) secondary to stage 4 undifferentiated metastatic carcinoma is granted. Service connection for an acquired psychiatric disorder, to include depressive disorder and anxiety disorder not otherwise specified (NOS) secondary to stage 4 undifferentiated metastatic carcinoma is granted. Service connection for residuals of skull trauma is denied. Service connection for the cause of the Veteran's death is granted. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Service connection for a right knee disability is remanded. Service connection for a left knee disability is remanded. Service connection for asthma is remanded. Service connection for irritable bowel syndrome (IBS) is remanded. Service connection for gastric ulcer is remanded. Service connection for stomach aches is remanded. Service connection for urinary tract infections is remanded. FINDINGS OF FACT 1. The Veteran served at Camp Lejeune for more than 30 days during active service. 2. The Veteran's metastatic embryonal cell carcinoma of the left testicle was related to in-service exposure to contaminated water at Camp Lejeune. 3. The Veteran's retroperitoneal carcinoma was proximately due to service-connected embryonal cell carcinoma of the left testicle. 4. The Veteran's ED was proximately due to service-connected embryonal cell carcinoma of the left testicle. 5. The Veteran's ED caused loss of use of a creative organ. 6. The Veteran's stage 4 undifferentiated metastatic carcinoma was proximately due to service-connected embryonal cell carcinoma of the left testicle. 7. The Veteran's lumbar spine neoplasm was proximately due to service-connected metastatic embryonal cell carcinoma of the left testicle. 8. The Veteran's lung neoplasm was proximately due to service-connected metastatic embryonal cell carcinoma of the left testicle. 9. The Veteran's brain neoplasm was proximately due to service-connected metastatic embryonal cell carcinoma of the left testicle. 10. The Veteran's lumbar vertebral fracture at L3 was proximately due to service-connected lumbar spine neoplasm. 11. The Veteran's nerve damage of the lumbar spine was proximately due to service-connected lumbar spine neoplasm. 12. The Veteran's muscle strain and weakness of the back and legs was proximately due to service-connected lumbar spine neoplasm. 13. The Veteran's peripheral neuropathy of the right lower extremity was proximately due to service-connected stage 4 undifferentiated metastatic carcinoma. 14. The Veteran's peripheral neuropathy of the left lower extremity was proximately due to service-connected stage 4 undifferentiated metastatic carcinoma. 15. The Veteran's cognitive disorder NOS was proximately due to service-connected stage 4 undifferentiated metastatic carcinoma. 16. The Veteran's depressive disorder and anxiety disorder NOS were proximately due to service-connected stage 4 undifferentiated metastatic carcinoma. 17. The Veteran did not have residuals of skull trauma at any time during or approximate to the pendency of the claim. 18. The Veteran died in May 2015 due to stage 4 testicular cancer of unknown cell type. 19. The Veteran's service-connected testicular cancer caused or contributed substantially or materially to his death. CONCLUSIONS OF LAW 1. The criteria for service connection for metastatic embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for retroperitoneal carcinoma as secondary to service-connected metastatic embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for ED secondary to service-connected metastatic embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for entitlement to SMC based on loss of use of a creative organ are met. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a)(1). 5. The criteria for service connection for stage 4 undifferentiated metastatic carcinoma secondary to service-connected embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for lumbar spine neoplasm secondary to service-connected metastatic embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for service connection for lung neoplasm secondary to service-connected metastatic embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 8. The criteria for service connection for brain neoplasm secondary to service-connected metastatic embryonal cell carcinoma of the left testicle are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 9. The criteria for service connection for lumbar vertebral fracture at L3 secondary to service-connected lumbar spine neoplasm are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 10. The criteria for service connection for nerve damage of the lumbar spine secondary to service-connected lumbar spine neoplasm are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 11. The criteria for service connection for muscle strain and weakness of the back and legs secondary to service-connected lumbar spine neoplasm are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 12. The criteria for service connection for peripheral neuropathy of the right lower extremity secondary to service-connected stage 4 undifferentiated metastatic carcinoma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 13. The criteria for service connection for peripheral neuropathy of the left lower extremity secondary to service-connected stage 4 undifferentiated metastatic carcinoma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 14. The criteria for service connection for cognitive disorder NOS secondary to service-connected stage 4 undifferentiated metastatic carcinoma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 15. The criteria for service connection for depressive disorder and anxiety disorder NOS secondary to service-connected stage 4 undifferentiated metastatic carcinoma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 16. The criteria for service connection for residuals of skull trauma are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 17. The criteria for entitlement to service connection for the cause of the Veteran's death are met. 38 U.S.C. §§ 1310, 5107; 38 C.F.R. §§ 3.102, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Marine Corps from October 1978 to October 1981, including more than 30 days of service at Camp Lejeune. This case comes to the Board of Veterans' Appeals (Board) on appeal from a December 2013 decision of the Agency of Original Jurisdiction (AOJ) that denied the Veteran's claims for service connection, special monthly compensation, and entitlement to a TDIU. The Veteran died in May 2015, and his surviving spouse has been substituted as the appellant for purposes of processing the claims to completion. 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. This case also comes to the Board on appeal from a September 2015 AOJ decision that denied the appellant's claim for service connection for the cause of the Veteran's death (one basis for dependency and indemnity compensation (DIC)). The Board notes that the Veteran's original claim referred to bone, lung, abdomen, and brain cancer. The evidence of record shows that his testicular cancer metastasized with neoplasms in the bone, lungs, abdomen, and brain. Thus, these issues have been recharacterized as reflected on the title page. The Board notes that the November 2018 and August 2020 briefs by the appellant's attorney erroneously included the issue of prostate cancer, which was not previously claimed and is not before the Board. Governing regulation provides that a substitute appellant may not add issues or expand a claim, but may raise new theories of entitlement. 38 C.F.R. § 3.1010(f)(2). In July 2019, the Board remanded this case to the AOJ for additional development. The case was subsequently returned to the Board. There has been substantial compliance with the Board's remand directives to obtain an addendum VA medical opinion regarding the claim of service connection for testicular cancer. The examiner was asked to address the medical literature cited by a private oncologist in an October 2018 private medical opinion, and to determine whether the facts of this particular case support a finding that the Veteran's testicular cancer was causally linked to his conceded exposure to contaminated drinking water while serving at Camp Lejeune. The remand instructed that if the examiner found that the Veteran's testicular cancer was causally linked to his exposure to contaminated water while serving at Camp Lejeune, the examiner should indicate which of the remaining claimed disabilities were present at any time during the pendency of the claim or recent to the filing of the December 2011 claim. Of those conditions present, the examiner was asked to opine whether they were causally linked to his testicular cancer and/or its metastasis. An addendum VA medical opinion was obtained in April 2020, and the appellant subsequently submitted a July 2020 supplemental private medical opinion by the same private physician who provided the October 2018 medical opinion. 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 elements required to establish service connection are: (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). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Certain chronic diseases 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). Service connection may be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (b). Service connection may be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service, in a veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). The following diseases shall be service-connected even though there is no record of such disease during service, subject to the rebuttable presumption provisions of 3.307 (d): kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309(f). The Veteran had active service in the USMC from October 1978 to October 1981, including more than 30 days of service at Camp Lejeune, and his primary military occupational specialty (MOS) was body repairman. The Board has previously conceded the Veteran's exposure to contaminated drinking water while serving at Camp Lejeune. 1. Service connection for testicular cancer 2. Service connection for retroperitoneal cancer (claimed as abdominal cancer), including as secondary to testicular cancer The appellant asserts that the Veteran's testicular cancer and abdominal cancer were due to exposure to contaminated water at Camp Lejeune during his service in the USMC. See the Veteran's December 2011 claim, the Veteran's statements dated in December 2011, January 2012, February 2012, and August 2012, and written briefs from the appellant's representative dated in November 2018 and August 2020. VA and private medical records reflect that during his lifetime, the Veteran was diagnosed with testicular carcinoma with metastasis to the retroperitoneum. VA treatment records dated from August to September 1987 show that the Veteran was diagnosed with stage C embryonal cell carcinoma of the left testicle, pathology undifferentiated intratubular type, and underwent a left radical orchiectomy in August 1987. At that time, he also had a retroperitoneal mass in his posterior abdomen, and the pathology report of that mass indicated a diagnosis of malignant cells, poorly differentiated germ cell neoplasm consistent with embryonal carcinoma. A November 1989 VA medical record indicated that the retroperitoneal mass was a metastasis of the testicular carcinoma. The retroperitoneum (retroperitoneal space) is defined as the subdivision of the extraperitoneal space between the posterior parietal peritoneum and the posterior abdominal wall. See Dorland's Illustrated Medical Dictionary 1741 (32nd ed. 2012). The peritoneum is the serous membrane lining the abdominopelvic walls and investing the viscera. Id. at 1418. As malignant tumors, left testicle carcinoma with metastasis to the retroperitoneum are enumerated conditions under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, testicular cancer and abdominal cancer were not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and were not noted in service with attributable continuity of symptomatology. VA and private treatment records show the Veteran was not diagnosed with testicular or abdominal cancer until August 1987, years after his separation from service and years outside of the applicable presumptive period. During the pendency of the appeal, the Veteran reported experiencing symptoms of diarrhea, stomachache during and immediately after service, and lower abdominal pain that started several months after service and resolved after private treatment for a urinary tract infection (see his December 2011 claim and statement). In January 2012, he stated that a few years after service, his symptoms changed, and he then had an onset of diffuse back pain, which became worse over time and was unbearable in mid-1984 or 1985. Although the Veteran asserted that he had gastrointestinal symptoms and lower abdominal pain shortly after service, neither he asserted nor does the appellant assert that he experienced any testicular symptoms prior to August 1987, or back pain prior to 1984. See his December 2011 claim and statement, and his subsequent statements. In this regard, the Board notes that a contemporaneous VA medical record dated in July 1987 shows that the Veteran was seen for back pain, but did not report a history of testicular or abdominal symptoms. Moreover, his service treatment records contain a December 1983 annual certificate of physical condition showing that the Veteran denied having any injury, illness or disease in the past 12 months that required hospitalization or caused absence from school or work for more than three consecutive days, and also denied having any physical defects that might restrict his performance on active duty. These inconsistencies reduce the probative value of his subsequent statements regarding continuity of symptomatology of testicular or abdominal cancer. While the Veteran was competent to describe his abdominal symptoms and back pain, he was not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of testicular cancer or abdominal cancer as he had not demonstrated the necessary medical expertise. Although he was trained as a respiratory therapist, he is not shown to have had medical expertise in oncology. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board finds that the evidence does not show continuity of symptoms of testicular cancer or abdominal cancer since service, and presumptive service connection is not warranted for testicular cancer with metastasis to the retroperitoneum under 38 C.F.R. § 3.309(a). Presumptive service connection is also not warranted for these disabilities under 38 C.F.R. § 3.309(f), because testicular cancer, retroperitoneal cancer, and abdominal cancer are not among the diseases listed for which presumptive service connection based on exposure to contaminated water at Camp Lejeune may be granted. Nevertheless, even if a Veteran is not entitled to a regulatory presumption of service connection for a given disability, the claim must be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Thus, the question becomes whether the diagnosed disabilities are related to service. On this question there are probative opinions in favor of and against the claim. Service treatment records reflect that in February 1979, the Veteran was seen for complaints of groin aches, with occasional acute pain for two weeks. The testes were examined, and there was slight tenderness of the right testis, but no abnormalities of the left testis were noted. The diagnostic assessment was questionable epididymitis, and antibiotics were prescribed. He was given a scrotal support a few days later. Subsequent service treatment records are negative for complaints, treatment, or diagnosis of a testicular condition or cancer. No pertinent abnormalities were noted on separation examination in September 1981. During the pendency of this appeal, the Veteran reported that he was treated by a private physician for diarrhea and stomachache shortly after separation from service, and for a urinary tract infection several months after service, but that the medical records of such treatment were unavailable. VA medical records dated from July to September 1987 show that in July 1987, the Veteran was seen for complaints of low back pain since September 1986, when he hurt his back moving furniture. He did not report a history of testicular or abdominal symptoms, and a physical examination was normal in this regard. A week later, he was seen for complaints of low back pain in the left flank area, urinary frequency and urgency, and a low grade fever. The nursing assessment was questionable urinary infection, but subsequent studies were negative. The Veteran continued to complain of low back pain, and an August 1987 computed tomography (CT) scan of the lumbar spine showed a large left paraspinous mass adjacent to the left kidney, and incidental disc disease on the right at L4-5. On examination, his left testicle was noted to be atrophic, and an August 1987 ultrasound of the testicles showed that the left testicle was small with multiple echogenic foci without a clearly defined mass, and several of the foci had shadowing suggesting calcifications. The right testicle was normal except for suggestion of varices. A left orchiectomy was performed in late August 1987, and the pathology report of the left testicle showed an intratubular germ cell tumor and testicular atrophy. He was diagnosed with stage C embryonal cell carcinoma of the left testicle and metastatic embryonal carcinoma of the retroperitoneum and underwent chemotherapy and surgical resection of the retroperitoneal mass. VA medical records dated from November 1989 to December 1989 reflect that the Veteran was seen for follow-up of his testicular carcinoma with metastasis, and in December 1989, an oncologist stated that the probability of a cure was very high as nothing was found on current evaluation, two years after treatment, to suggest recurrence. Subsequent private medical records reflect treatment for several other neoplasms throughout his body from 2005 to 2015. The evidence against the claim includes a July 2012 VA examination and September 2012 VA medical opinion, in which the examiner opined that the Veteran's testicular cancer and abdominal cancer were not at least as likely as not related to an in-service injury, event, or disease, including exposure to exposure to contaminated water at Camp Lejeune. The rationale was that the conditions had not been associated with his exposure to contaminated water at Camp Lejeune, and that the research was based on the National Research Council's (NRC) report. The Board previously found this medical opinion inadequate, as the examiner did not address the theory of direct service connection. Additional evidence weighing both against and in favor of the claim includes articles submitted by the Veteran in December 2011. An article from SymptomFind indicated that the cause of testicular cancer was unknown, but the same risk factors for other cancers seemed to play a part. The article stated that testicular problems were believed to be a factor in some cases, as when a testicle developed abnormally or did not descend on its own, but no concrete links had been identified between these conditions and cancer. Smoking, obesity, a poor diet, alcohol consumption, and exposure to cancer-causing chemicals and substances (carcinogens) increase the risk of every type of cancer, including testicular cancer. An article from eMedicine Health stated that it was not known exactly what caused testicular cancers, and certain factors increased the risk including cryptorchidism, exposure to DES in the womb, testicular atrophy, and exposure to certain drugs. The article stated that exposure to certain toxic substances might cause the testicles to develop abnormally. The evidence against the claim includes a September 1987 VA medical record indicating that the Veteran was always noted to have an atrophic left testicle, a September 1987 pathology report of the left testicle showing an intratubular germ cell tumor and testicular atrophy, and a December 1989 VA oncology note indicating that the Veteran had an undifferentiated intratubular type neoplasm. In an October 2018 private medical opinion, C.R., MD, indicated that the risk factors for testicular neoplasms included germ cell neoplasia in situ (GCNIS) but did not find that this risk factor applied to the Veteran. The Board notes that testicular GCNIS was formerly known as intratubular germ cell neoplasia of the unclassified type. Additional evidence weighing against the claim includes an April 2020 VA medical opinion in which the examiner opined that the Veteran's testicular cancer was not at least as likely as not related to an in-service injury, event, or disease, including exposure to contaminated water at Camp Lejeune. The rationale was that he served at Camp Lejeune for about 6.5 months, and data from the Agency for Toxic Substances and Disease Registry (ATSDR) did not show an association between Camp Lejeune water contaminant exposures and the development of testicular cancer. The examiner stated that risk factors for testicular cancer included an undescended testis, family history of the disease, and previous history of testicular cancer, and the most common type (more than 95 percent) was germ cell tumors. The VA examiner also reviewed and commented on an October 2018 private medical opinion from C.R., MD, and noted that Dr. R. did not discuss the length of the Veteran's term of service at Camp Lejeune, which was a very short period of time for an exposure to conceivably lead to a later, distant effect. The length of time that the bulk of subjects in the literature cited by Dr. R. were potentially exposed to volatile organic compounds (VOCs) was most often years, not a few months, making the possible connection even more tenuous. The examiner also stated that Dr. R. ignored the fact that the Veteran seemed to have developed back pain (an initial presentation of some malignant pathology) about 4 to 5 years after exposure, which is an extremely short latency period. The examiner indicated that typically, when there is some sort of exposure leading to a malignancy (like sunburned skin leading to melanoma), there are extensive latency periods, often exceeding 20 years, before pathology is manifest, thus making this association harder to accept. The VA examiner noted that Dr. R. cited literature of clinical studies of Sprague-Dawley rats and exposures to VOCs, and development of testicular cancers, and said that although rat and animal studies are of great value in medical science, a direct correlation between animal studies and humans varies widely, and it is not remotely accurate to state that because these rat studies show an association, this too would occur in humans. The examiner noted that Dr. R. also cited studies of firefighters noting an increase in testicular cancer, but it appeared that their exposure time was much longer than the Veteran's, and they likely had a much greater concentration of exposure to chemicals than that to which the Veteran was exposed. The VA examiner opined that ultimately, the firefighter study did not demonstrate a clear cause and effect of the exposure and the condition of testicular cancer, and added that Dr. R. did not acknowledge that in the vast majority of cases of any sort of malignancy, no specific risk factor or exposure is ever identified as being causal in leading to cancer, to the misfortune of many. Thus, taken together with the ATSDR epidemiological data, and Dr. R.'s assertions, the clinical conclusion remains that the claimed condition is less likely as not caused by or a result of the Veteran's exposure to contaminated water at Camp Lejeune. The examiner cited the ATSDR, the CDC website, and 49 articles to support the opinion. The evidence in favor of the claim includes private medical opinions from C.R., MD dated in October 2018 and July 2020. In the October 2018 private medical opinion, Dr. R., a Board certified radiation oncologist, opined that after reviewing the Veteran's claims file and medical records, and the multitude of literature on the subject, his toxin exposure at Camp Lejeune, including VOCs, TCE, PCE, vinyl chloride, and benzene compounds more likely than not contributed to the development of metastatic testicular cancer and it should be considered service-connected. She opined that the Veteran had a germ cell testicular cancer, most likely a non-seminomatous germ cell tumor, and that all of his subsequent cancers originated from his original testicular cancer and that they were caused by his exposure to toxic VOCs at Camp Lejeune. Dr. R. cited a study regarding testicular tumors in rats exposed to TCE, and a study of firefighters exposed to benzene, polycyclic hydrocarbons, and chromium compounds. Dr. R. indicated that the risk factors for testicular neoplasms included cryptorchidism or undescended testicle, hypospadias, germ cell neoplasia in situ (GCNIS), polyvinyl chloride exposure, contralateral testicular cancer, extragonadal germ cell tumor, a family history of testicular cancer, HIV infection, Klinefelter's syndrome, Down syndrome, and being a white male. She stated that although the Veteran's medical records noted that he was a former smoker, a smoking history was not a known risk factor for development of testicular cancer. Dr. R. stated that after reviewing his medical records, she could find no major risk factors for the development of testicular cancer other than being white and his exposure to contaminated water at Camp Lejeune. In a July 2020 private medical opinion, Dr. R. responded to the April 2020 VA medical opinion, and stated that clearly there is a connection between animals and humans developing testicular cancer when exposed to VOCs, and there is no absolute time frame between when someone is exposed to a carcinogen and when a cancer subsequently develops. She highlighted that an article by Beranger et al. reported on occupational and environmental exposures associated with testicular germ cell tumors, which found a statistically increased risk for Swedish plastic industry workers exposed to polyvinyl chloride, and noted that the stratification for time between first exposure and diagnosis did not follow any specific trend. Dr. R. stated that she totally disagreed with the VA examiner's opinion that the toxic water had no role in the development of the Veteran's testicular cancer. She concluded that her opinion remained that the Veteran's toxic water exposure, during his service at Camp Lejeune, as likely as not caused his metastatic testicular cancer and that this cancer resulted in his death. Thus, the metastatic testicular cancer substantially or materially caused his death. The July 2012 VA examiner opined that the Veteran's stage 4 undifferentiated metastatic carcinoma, bone cancer, and abdominal cancer were all part of the same diagnosis of metastatic testicular cancer. Upon review of the evidence of record, the Board finds that the evidence is in approximate balance and the benefit-of-the-doubt rule is applicable. After resolving reasonable doubt in the appellant's favor, the Board concludes that during his lifetime, the Veteran had testicular carcinoma with metastasis to the retroperitoneum that is related to exposure to contaminated water at Camp Lejeune. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 3. Service connection for ED, including as secondary to testicular cancer 4. SMC for loss of use of a creative organ The appellant asserts that the Veteran had ED secondary to now service-connected testicular carcinoma. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The July 2012 VA examination shows that the Veteran had a current disability of ED, and the VA examiner opined that it was at least as likely as not proximately due to or the result of his now service-connected testicular cancer. The examiner opined that the etiology of his ED was surgical lymph node dissection. The rationale was that the Veteran started to have ED after he underwent an orchiectomy, and required the orchiectomy for treatment of his testicular cancer. Upon review of the record, the Board finds that the evidence is in at least approximate balance and the benefit-of-the-doubt rule is applicable. The Board concludes that during his lifetime, the Veteran had ED secondary to service-connected testicular carcinoma. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Lynch, supra. The Board also grants entitlement to SMC based on loss of use of a creative organ, based on the award of service connection for ED. SMC is payable at a specified rate if a veteran, as the result of service-connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C. § 1114 (k); 38 C.F.R. § 3.350 (a)(1). 5. Service connection for stage 4 undifferentiated metastatic carcinoma 6. Service connection for bone neoplasm 7. Service connection for lung neoplasm 8. Service connection for brain neoplasm 9. Service connection for lumbar vertebral fracture 10. Service connection for nerve damage in the back 11. Service connection for muscle strain and weakness in the low back and legs 12. Service connection for peripheral neuropathy of the right lower extremity 13. Service connection peripheral neuropathy of the left lower extremity 14. Service connection for a cognitive disorder (claimed as a memory condition) The appellant asserts that the Veteran had multiple conditions due to exposure to contaminated water at Camp Lejeune, or alternatively that they are secondary to testicular cancer, to include stage 4 undifferentiated metastatic carcinoma, bone cancer, lung cancer, and brain cancer. The appellant also asserts that the Veteran's lumbar vertebral fracture, nerve damage in the back, muscle strain and weakness in the low back and legs, and peripheral neuropathy of the right and left lower extremities were all secondary to bone cancer with resulting lumbar vertebral fractures. See the Veteran's December 2011 claim, the Veteran's statements dated in December 2011, January 2012, February 2012, and August 2012, and written briefs from the appellant's representative dated in November 2018 and August 2020. The appellant also states that the Veteran had memory/cognitive problems due to brain cancer and the chemotherapy and radiation treatment for such cancer. The question for the Board is whether the Veteran had a current disability during his lifetime that began during service, was at least as likely as not related to an in-service injury, event, or disease, or was proximately due to or the result of, or aggravated beyond its natural progress by service-connected disability. VA and private medical records reflect that the Veteran was diagnosed with stage 4 metastatic adenocarcinoma to the lumbar spine of unknown primary, metastatic adenocarcinoma with unknown primary to the bilateral lungs, metastatic brain cancer of unknown primary but suspected testicular origin, malignant metastatic adenocarcinoma of the paraspinal area, stage 4 metastatic testicular cancer to the bone, lung, and brain, degenerative changes of the lumbar spine, a pathologic burst vertebral fracture of L3 with metastatic cancer, spinal fracture and spinal metastasis of the lumbar spine, and peripheral neuropathy of the legs. See June 2010 private physician's certification completed by J.G., MD, VA examinations dated in July 2012 and May 2013, private medical records from Arizona Oncology Services dated from February to May 2005, private medical records from A.B., MD dated from July to December 2008, private medical records from Cancer Treatment Centers of America dated from February 2009 to January 2010, private medical records from MD Anderson Cancer Center dated in 2012, and private medical records from I.F, MD dated in 2012. The Veteran has also been diagnosed with cognitive disorder not otherwise specified (NOS), bilateral leg weakness, nerve damage in the back, muscle strain and weakness, painful sensory neuropathy, motor weakness in the legs, memory trouble, and neurocognitive issues. See July 2012 VA psychological examination and general medical examination, and May 2013 VA central nervous system examination. Malignant neoplasms of the lumbar spine, lungs, and brain are enumerated conditions under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Arthritis and organic diseases of the nervous system are also enumerated conditions under 38 C.F.R. § 3.309(a). However, these claimed conditions were not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and were not noted in service with attributable continuity of symptomatology. VA and private treatment records show the Veteran was not diagnosed with cancer of the spine or a lumbar vertebral fracture until February 2005, with lung cancer until July 2008, with peripheral neuropathy until May 2009, or with brain neoplasm until December 2009, years after his separation from service and years outside of the applicable presumptive period. The appellant does not assert, and the evidence does not otherwise reflect, that the Veteran had continuous symptoms of the claimed conditions since service. The Board finds that presumptive service connection is not warranted for these conditions under 38 C.F.R. § 3.309(a). Presumptive service connection is also not warranted for these disabilities under 38 C.F.R. § 3.309(f), because they are not among the diseases listed for which presumptive service connection based on exposure to contaminated water at Camp Lejeune may be granted. Nevertheless, even if a Veteran is not entitled to a regulatory presumption of service connection for a given disability, the claim must be reviewed to determine whether service connection can be established on direct or secondary bases. Service treatment records are negative for pertinent abnormalities. A December 1983 annual certificate of physical condition shows that the Veteran denied having any injury, illness or disease in the past 12 months that required hospitalization or caused absence from school or work for more than three consecutive days, and also denied having any physical defects that might restrict his performance on active duty. VA medical records dated in August 1987 reflect that an X-ray study of the lumbosacral spine showed Schmorl's nodes at multiple levels in the lumbar spine, but was otherwise negative. A CT scan of the lumbar spine showed midline disc bulge at L4-5, asymmetrical disc bulge right greater than left at L5-S1, and a 5- centimeter mass anterior to the left psoas. A chest X-ray study showed no evidence of a mediastinal mass, and no active disease in the chest. A September 1987 VA discharge summary reflects that the Veteran reported that he smoked one pack of cigarettes per day. A December 2004 private magnetic resonance imaging (MRI) scan of the lumbar spine reflects a diagnostic impression of L3 pathological compression fracture. Private medical records from Banner Health reflect that in February 2005, the Veteran was diagnosed with a pathologic burst fracture of L3 with metastatic cancer. He underwent a laminectomy at L3 and posterior spinal fusion at L2-L4. A biopsy was performed, and the pathology report showed metastatic poorly differentiated adenocarcinoma, with a gastrointestinal tract or genitourinary tract primary neoplasm being favored for the metastasis. Private medical records from G.M., MD, of Arizona Oncology Services dated from April to May 2005 reflect a diagnosis of metastatic adenocarcinoma to the lumbar spine of unknown primary, stage 4 disease, and show that the Veteran underwent radiation therapy. Private medical records from Dr. B. and Cancer Treatment Centers of America reflect treatment for lung cancer in July 2008, including chemotherapy with Taxol and Cisplatin, and indicate that he developed chemotherapy-induced neuropathy. In December 2008, Dr. B. diagnosed metastatic adenocarcinoma with unknown primary to the bilateral lungs. A May 2009 private medical record from the Arizona Institute of Medicine reflects a diagnosis of neuropathy secondary to Taxol. A December 2009 private medical record from Cancer Treatment Centers of America reflects a diagnostic assessment of metastatic brain lesion, metastatic cancer unknown primary but suspected testicular origin, bilateral pulmonary masses of suspected testicular origin, chemotherapy-induced neuropathy, history of testicular cancer with metastasis to spine L3, L3 pathologic fracture status post laminectomy/ fusion and radiation therapy, and left orchiectomy. He underwent surgical resection of the brain metastasis and whole brain radiation. Private medical records dated from January to February 2012 from K.P., MD, reflect that he was diagnosed with obesity, neuropathy due to drugs in both legs along with tingling and numbness, and chronic back pain. In February 2012, he was diagnosed with backache secondary to vertebral metastasis with L3 compression fracture and malignant neoplasm of the testis with new metastasis to the L3 vertebra, and neuropathy due to Taxol. A February 2012 private MRI scan of the lumbar showed a L3 metastatic lesion with compression fracture, L3 bilateral laminectomy with L2-L4 pedicle screw fixation, small broad-based L4-5 posterior disc protrusion, and small L5-S1 posterior midline disc extrusion with mild impingement on both emerging S1 nerve roots. A March 2012 private MRI of the spine showed pathologic compression fracture at L3 with bulky paraspinous tumor extension on the left that invaded the left psoas muscle and likely mechanically compressed the descending left ureter resulting in hydronephrosis, foraminal and subarticular compromise by epidural tumor with likely impingement of L3 nerve root in the foramen and L4 nerve root in the subarticular recess, osseous metastatic disease involving the anterior aspect of the L4 vertebral body. Private medical records from MD Anderson dated in March 2012 reflect a history of testicular cancer, and a diagnosis of metastatic cancer including to the lymph nodes, bone, lung, and brain. A March 2012 biopsy of the paraspinal area was malignant and consistent with metastatic adenocarcinoma. Private imaging studies from MD Anderson dated in March 2012 reflect a diagnostic impression of left frontal craniotomy and underlying resection but no abnormal enhancement to suggest either residual or recurrent tumor. In June 2012, a private physician, I.F., MD, indicated a diagnostic assessment of testicular cancer diagnosed in 1987 and metastatic disease to the lumbar spine addressed in 2005, currently on chemotherapy with side effects most likely from peripheral neuropathy. With regard to the claims of service connection for neoplasms of the lumbar spine, lungs, brain, and stage 4 metastatic carcinoma, the July 2012 VA examiner indicated that the Veteran's stage 4 undifferentiated metastatic carcinoma and bone cancer were part of the same diagnosis of metastatic testicular cancer. A private physician, Dr. G., diagnosed metastatic testicular cancer to the bone, lung, and brain, stage 4. See June 2010 physician's certification. Dr. R. opined that all of the Veteran's subsequent cancers originated from his original testicular cancer and that they were caused by his exposure to toxic VOCs at Camp Lejeune. See October 2018 private medical opinion. Upon review of the record, the Board finds that the evidence is in at least approximate balance and the benefit-of-the-doubt rule is applicable. The Board concludes that the Veteran's stage 4 metastatic carcinoma and neoplasms of the lumbar spine, lungs, and brain are at least as likely as not secondary to service-connected testicular carcinoma. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Lynch, supra. With regard to the claims of service connection for lumbar vertebral fracture, nerve damage in the back, muscle strain and weakness in the low back and legs, cognitive disorder, and peripheral neuropathy of the right and left lower extremities, private medical records show that in February 2005, he was diagnosed with pathologic burst fracture of L3 with metastatic cancer, and underwent a laminectomy at L3 and posterior spinal fusion at L2-L4. Private medical records from Cancer Treatment Centers of America reflect a diagnosis of chemotherapy-induced neuropathy. Dr. G. indicated that the Veteran had undergone chemotherapy and radiation therapy for his metastatic cancer to the bone, lung, and brain, stage 4, which resulted in severe peripheral neuropathy. The July 2012 VA psychological examiner opined that the Veteran's cognitive disorder NOS was related to his multiple medical issues (including cancer diagnoses and treatments). The July 2012 VA general medical examiner opined that the Veteran's bilateral leg weakness, nerve damage in the back, muscle strain, and muscle weakness were at least as likely as not proximately related to the Veteran's spinal metastasis. The rationale was that the Veteran had surgical resection of a spinal metastasis, which resulted in back pain and bilateral leg weakness as well as nerve damage. The May 2013 VA central nervous system examiner diagnosed a brain tumor, memory trouble and neurocognitive issues, trouble with concentration, depression, and anxiety, and opined that the Veteran had the following residual conditions of neoplasm (including metastases) or its treatment: painful sensory neuropathy and motor weakness in the legs, and memory and cognitive complaints. The examiner stated that the Veteran required continuous medication for control of neuropathic pain for which the cause was likely multifactorial, and suspected that this was a painful peripheral sensory neuropathy that could be directly related to the chemotherapy, paraneoplastic polyneuropathy, or other cause. The examiner indicated that the Veteran had an abnormal gait which was contributed to by the following conditions: peripheral sensory neuropathy causing faulty proprioceptive input to the central nervous system hence rendering him with a sensory ataxia, and motor nerve involvement causing weakness in the legs, left greater than right, causing asymmetrical hemiparetic ambulation. The examiner opined that the weakness might be due to damage of the nerve roots in the lumbosacral spine either as a result of direct cancer invasion and/or post radiation effects causing nerve damage. Upon review of the record, and resolving reasonable doubt in the appellant's favor, the Board finds that the evidence is in at least approximate balance and the benefit-of-the-doubt rule is applicable. The Board concludes that it is at least as likely as not that the Veteran's vertebral fracture of L3 is proximately due to now service-connected lumbar spine neoplasm, and that it is at least as likely as not that his nerve damage in the back, and muscle strain and weakness in the low back and legs are proximately due to now service-connected lumbar spine neoplasm and vertebral fracture, including the treatment for his metastatic carcinoma (surgery, radiation, and chemotherapy). The Board also concludes that the Veteran's peripheral neuropathy of the right and left lower extremities and cognitive disorder NOS are proximately due to his stage 4 metastatic carcinoma, including the treatment for such carcinoma (radiation and chemotherapy). See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Lynch, supra. 15. Service connection for an acquired psychiatric disorder, including as secondary to testicular cancer The appellant asserts that the Veteran had an acquired psychiatric disorder, including depression and anxiety, secondary to testicular cancer, stage 4 undifferentiated metastatic carcinoma, and his secondary conditions. See the Veteran's December 2011 claim, the Veteran's statements dated in December 2011, January 2012, February 2012, and August 2012, and written briefs from the appellant's representative dated in November 2018 and August 2020. The question before the Board is whether the Veteran had an acquired psychiatric disorder that is proximately due to or aggravated by service-connected disability. VA and private medical records dated since May 2009 show that the Veteran had a current psychiatric disorder, variously diagnosed as depression, anxiety disorder, and ADHD. A May 2009 private medical record from the Arizona Institute of Medicine reflects diagnoses of anxiety and depression. Private medical records dated from November 2011 to January 2012 from a private physician, E.H., DO, reflect treatment for diagnoses of major depressive disorder, recurrent, moderate, ADHD, combined type, and anxiety disorder not otherwise specified (NOS). In November 2011, the Veteran reported that he had been struggling with depression for since his cancer diagnosis in his 20s, and had ADHD since he was a child. He said he had been on multiple medications for ADHD and depression, and reported significant depression for the past 10 years. Dr. H. opined that the Veteran's depression symptoms seemed to be worsening, that he had ADHD symptoms for his whole life, and that he might be having difficulties with anxiety which could be masquerading as depression. At a July 2012 VA psychological examination, the Veteran reported that his depression began approximately 20 years ago when he was between marriages. He said he currently felt anxious, irritable, and depressed due to his numerous health issues and concerns about his future including finances. The VA examiner opined that the Veteran's anxiety disorder NOS was related to his multiple medical issues (including cancer diagnoses and treatments). The examiner also opined that the Veteran's anxiety disorder NOS originated as a result of his first failed marriage as well as health issues. The May 2013 VA central nervous system examination reflects diagnoses of a brain tumor, memory trouble, neurocognitive issues, and trouble with concentration, depression, and anxiety. The examiner opined that the Veteran had mental health conditions attributable to a central nervous system disease and/or its treatment. The VA examiner opined that the Veteran had residuals of neoplasm, including both physical and cognitive functional impairment, and his severe pain required chronic opiate medication, neuropathic pain modulating medication, antidepressants, and mood stabilizers. The Board finds that the evidence does not persuasively show that ADHD is related to service or is proximately due to or aggravated by a service-connected disability. In this regard, the Board notes that the Veteran has not presented any arguments with regard to this disorder, he told his treating medical provider that he had the condition since childhood, Dr. H. opined that he had ADHD symptoms throughout his life, and there is no medical evidence linking ADHD with service or a service-connected disability. As the evidence is not in approximate balance, or nearly equal, the benefit-of-the-doubt rule is inapplicable, and service connection is not warranted for ADHD. With regard to depressive disorder and anxiety disorder NOS, upon review of the record, the Board finds that the evidence is in at least approximate balance and the benefit-of-the-doubt rule is applicable. The Board concludes that the Veteran's depressive disorder and anxiety disorder NOS are at least as likely as not secondary to service-connected stage 4 metastatic carcinoma. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; Lynch, supra. 16. Service connection for residuals of skull trauma The appellant asserts that the Veteran had residuals of skull trauma from his surgery for brain cancer in December 2009. See the Veteran's February 2012 statement, in which he reported that skull trauma from his brain cancer surgery made recovery from the surgery difficult, and he had a large incision to the left front of his skull. The question for the Board is whether the Veteran had a current skull disability that was proximately due to or aggravated by a service-connected disability. The Board concludes that the Veteran did not have a current diagnosis of residuals of skull trauma and did not have one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Private medical records from Cancer Treatment Centers of America reflect that the Veteran was diagnosed with a metastatic carcinoma of the left frontal lobe of the brain, and underwent a craniotomy and surgical resection of the tumor in late December 2009. On examination in February 2010, he had a healing craniotomy scar involving the left frontal area. No skull defects were noted. In contrast to his February 2012 statement, at the July 2012 VA examination, the Veteran denied a history of skull trauma. Residuals of skull trauma were not diagnosed at the July 2012 VA examination, or at the May 2013 VA central nervous system examination, though both examiners examined him and noted that he previously had a brain tumor that was resected. Further, despite consistent treatment for multiple medical conditions from December 2009 to May 2015, VA and private treatment records do not contain a diagnosis of residuals of skull trauma or residuals of craniotomy. While the Veteran at one point asserted that he had a current diagnosis of residuals of skull trauma, he subsequently denied having this condition. Moreover, the appellant and the Veteran are not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education, knowledge of the interaction between multiple organ systems in the body, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Without evidence of a current disability or evidence of symptoms that result in functional impairment of earning capacity, service connection for residuals of skull trauma is not warranted. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). As the competing evidence is not in approximate balance, or nearly equal, the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, supra. DIC 17. Entitlement to service connection for the cause of the Veteran's death The appellant asserts that the Veteran's death was caused by service-connected testicular cancer. In order to establish service connection for the cause of a veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312. In order to be a contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially to cause death; that it combined to cause death; or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312 (c)(2). During the Veteran's lifetime, service connection was not in effect for any disabilities. As a result of the instant decision, service connection has been granted for metastatic embryonal cell carcinoma of the left testicle. The Veteran's death certificate shows that he died in May 2015 due to an immediate cause of death of stage 4 testicular cancer of unknown cell type. A private physician, Dr. R. opined that the Veteran's toxic water exposure, during his service at Camp Lejeune, as likely as not caused his metastatic testicular cancer and that this cancer resulted in his death. Thus, the metastatic testicular cancer substantially or materially caused his death. See Dr. R.'s October 2018 and July 2020 private medical opinions. After resolving all doubt in the appellant's favor, the Board finds that the service-connected metastatic embryonal cell carcinoma of the left testicle as likely as not contributed substantially or materially to cause the Veteran's death. Accordingly, service connection for the cause of the Veteran's death is granted. REASONS FOR REMAND 18. TDIU As a result of the instant decision, service connection has been established for multiple disabilities. The AOJ must assign the service-connected disability ratings for these disabilities in the first instance. The issue of entitlement to a TDIU is remanded to the AOJ for assignment of service-connected disability ratings and readjudication of the TDIU claim. 19. Service connection for a right knee disability is remanded. 20. Service connection for a left knee disability is remanded. The Board cannot make a fully-informed decision on the issues of service connection for right and left knee disabilities, as no VA examiner has opined whether the bilateral knee degenerative changes noted in February 2009 are related to the bilateral chondromalacia patella diagnosed in service. See private medical records received on February 16, 2012, and service treatment records dated in October 1979, January 1980 and February 1980. A November 2013 VA examiner provided a negative medical opinion regarding the claims of service connection for bilateral knee disabilities, and noted that the Veteran had right knee chondromalacia patella in service, and currently had arthritis of the bilateral knees but no right knee chondromalacia patella. However, the examiner did not address the relationship, if any, between the two conditions and relied on the lack of documented evidence, warranting remand. 21. Service connection for asthma is remanded. The Board cannot make a fully-informed decision on the issue of service connection for asthma because no VA examiner has opined whether his diagnosed asthma is related to his documented asbestos exposure in service. Moreover, in light of the instant award of service connection for several disabilities including metastatic carcinoma and lung neoplasm, an addendum opinion should be obtained as to whether asthma is proximately due to or aggravated beyond its natural progression by these service-connected disabilities or the treatment for such disabilities. 22. Service connection for IBS is remanded. 23. Service connection for gastric ulcer is remanded. 24. Service connection for stomachaches is remanded. 25. Service connection for urinary tract infections is remanded. In light of the instant award of service connection for several disabilities including retroperitoneal carcinoma and metastatic carcinoma, an addendum VA medical opinion should be obtained as to whether IBS, gastric ulcer, stomachaches and/or urinary tract infections are proximately due to or aggravated beyond their natural progression by these service-connected disabilities or the treatment for such disabilities. The matters are REMANDED for the following action: 1. Assign initial disability ratings for the Veteran's newly service-connected disabilities, and readjudicate the TDIU claim. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's right and left knee arthritis and degenerative changes were at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to bilateral chondromalacia patella diagnosed in service. The claims file must be reviewed, including the July 2012 VA examination, the November 2013 VA medical opinion (CAPRI, received on August 2, 2018), private medical records dated in 2009 (received on February 16, 2012), and service treatment records dated in October 1979, January 1980, and February 1980. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's asthma was at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (a) related to asbestos exposure in service; (b) proximately due to service-connected disability (to include metastatic carcinoma and lung neoplasm, and the treatment for such disabilities); or (c) aggravated (worsened) by service-connected disability. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's IBS, gastric ulcer, stomachaches and/or urinary tract infections were at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (a) proximately due to service-connected disability (to include metastatic carcinoma and retroperitoneal carcinoma, and the treatment for such disabilities); or (b) aggravated (worsened) by service-connected disability. A complete rationale for the examiner's opinion should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. L. Wasser, 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.