BVA9501976 DOCKET NO. 90-22 887 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Stephen J. Hogg, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J.P. Reep, Associate Counsel INTRODUCTION The veteran served on active duty from October 1960 to December 1980. He died on April [redacted] 1989. The appellant is his widow. This matter came before the Board of Veterans' Appeals (the Board) on appeal from an August 1989 rating decision of the Montgomery, Alabama Regional Office (RO) of the Department of Veterans Affairs (VA), which denied service connection for the cause of the veteran's death. The appellant testified before a hearing officer in April 1990. The hearing officer issued a decision in May 1990. The case was received at the Board in August 1990. By decision dated April 23, 1991, the Board denied the appellant's claim. The following month, the appellant's representative at the time, Disabled American Veterans, submitted a motion for reconsideration of the Board's decision. The case was returned to the Board in November 1991. Pursuant to 38 U.S.C.A. § 7103 (West 1991), the Chairman ordered reconsideration of the decision by an expanded panel of the Board. In June 1992, the case was remanded by the Board for further evidentiary development. The Board instructed the RO to obtain tissue samples and slides from the Mayo Clinic in Rochester, Minnesota. The tissue samples and slides were returned to the Board in September 1992. In April 1993, the Board forwarded the tissue samples and slides, along with the veteran's claims folder, to the Armed Forces Institute of Pathology (AFIP). Following review of the evidence, the AFIP issued an opinion dated in May 1993. In compliance with the ruling of the United States Court of Veterans Appeals (the Court) in Thurber v. Brown, 5 Vet.App. 119 (1993), the Board forwarded the veteran's claims folder, containing the AFIP opinion, to the appellant's representative. In November 1993, the appellant's representative submitted written argument to the Board. In a May 18, 1994 decision, the Board again denied entitlement to service connection for the cause of the veteran's death. The appellant appealed to the Court, appearing pro se. By an August 10, 1994 order, the Court remanded the case to the Board to afford the appellant an opportunity to submit additional evidence. In September 1994, the Board received notice, from Stephen J. Hogg, Attorney-at-Law, that he is representing the appellant. Notice was printed on his letterhead. The case is currently before an expanded panel of the Board. This decision replaces the May 18, 1994 decision (which had replaced the April 23, 1991 decision), and constitutes the final decision of the Board. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that she is entitled to service connection for the cause of her husband's death. She maintains that the squamous cell carcinoma of the left parotid gland, which caused the veteran's demise, first manifested during service. She further maintains that this type of cancer is slow growing, and manifests with little or no symptomatology until it is large enough to be diagnosed. To support her contentions, the appellant argues that the following inservice symptoms were in fact early manifestations of carcinoma of the left parotid gland: problems with teeth on the left side of the jaw, occasional locking of the left jaw, recurring ear infections, and chronic earaches. She emphasizes that the ear infections were present throughout 17 years of active duty, that they intensified toward the end of service, and continued up until the veteran's death. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for the cause of the veteran's death. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. The immediate cause of the veteran's death was squamous cell carcinoma of the left parotid gland, extensive recurrent, Stage IV. The approximate interval between the onset of the carcinoma and death was noted to be six months. 3. At the time of the veteran's death, he had no adjudicated, service-connected disabilities. 4. Carcinoma of the left parotid gland was not manifested during active military service, or within one year following service, and is not otherwise attributable to active service. 5. No disability of service origin is shown to have contributed in a substantial or material manner to cause death. CONCLUSION OF LAW The veteran's death was not caused, or contributed to, by disability incurred in or aggravated by active military service, nor by a disability which may be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1310, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309, 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds that the appellant's claim is well grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). That is, we find that she has presented a claim which is plausible. We are also satisfied that all relevant facts have been properly developed. No further assistance to the appellant is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. §§ 3.103(a), 3.159 (1993). The veteran died on April [redacted] 1989, at age 46. His official death certificate indicates that he died at the hospital, and that the immediate cause of death was squamous cell carcinoma of the left parotid gland, extensive recurrence, Stage IV. The approximate interval between onset and death was six months. No autopsy was performed. At the time of his death, the veteran had no adjudicated, service- connected disabilities. To establish service connection for the cause of the veteran's death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. For a service-connected disability to constitute a contributory cause, it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 U.S.C.A. § 1310 (West 1991); 38 C.F.R. § 3.312 (1993). In addition, certain diseases, such as malignant tumors, when manifest to a degree of 10 percent or more within one year after the veteran's military service ended, may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112(a) (West 1991); 38 C.F.R. §§ 3.307, 3.309(a) (1993). The presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C.A. § 1113 (West 1991); 38 C.F.R. § 3.307(d) (1993). I. Evidence The record has been thoroughly reviewed. Service medical records contain no documented findings of carcinoma, or of any recorded complaints or symptoms clinically attributed to carcinoma. Various entries in the service medical records, dated from 1962 to 1980, reflect treatment for upper respiratory infections, occasionally manifested by mucus flow. Several entries in the service medical records, dated in 1967 and in 1976, reflect treatment for ear infections. In October 1975, the veteran was treated on several occasions for a right-side, impacted tooth. A dental examination conducted later that month revealed that he was healing well. An August 1977 periodic examination was negative for any pertinent defects. On the report of the veteran's November 1980 retirement examination, the only potentially significant defects noted were bilateral mandibular exostosis on the lingular aspect, and bilateral boggy turbinates of the nose. In November 1987, the veteran underwent a physical examination, conducted at a service department facility. He reported no relevant complaints. According to the report, which includes a medical history questionnaire, the only defect noted was mild anemia. In December 1987, he was treated after tearing the pinna of the right ear, while getting into a car. No left-sided complaints or findings were recorded. Submitted into the record were dental records, compiled at a service medical facility. Entries dated in December 1987 reflect no complaints or significant findings. In May 1988 it was noted that the veteran complained of pain on the left side, of one week's duration, radiating to the left ear, and limiting the opening of his mouth. A mild sensitivity in the upper left molar area and facial swelling were reported. Medication was prescribed and civilian periodontal treatment recommended. In June 1988 emergency room records, it was noted that he had a 3 day history of left jaw, neck, and ear pain, diagnosed at that time as temporomandibular joint misalignment with acute pain. An October 1988 letter from Michael Fasching, M.D., of the Mayo Clinic, reports that the veteran had a Grade IV squamous cell carcinoma. Dr. Fasching notes that it appeared to originate in the deep lobe of the parotid gland, and that there was some element of a mucoepidermoid carcinoma. The record contains an October 1988 letter from Robert L. Foote, M.D., of the Mayo Clinic. The letter indicates that, early that summer, the veteran had noted the onset of progressive trismus that was initially believed to be a dental problem. A mass in the submandibular area was later discovered. CT scan revealed that the nasopharynx and hypopharynx were displaced medially; the parotid gland, laterally. The medial and lateral pterygoid muscle appeared to have been involved. According to Dr. Foote, the veteran underwent the following procedures in October 1988: a left modified radical neck dissection, left subtotal parotidectomy, left mandibular osteotomy, dissection of the infratemporal fossa, and reconstruction of the mandible, temporalis fascia flap and hemisternocleidomastoid flap. It was noted that, during the week prior to the surgery, the veteran had complained of left ear pain and hearing loss. It was also noted that the veteran had status post resection, with an extremely high likelihood of residual disease. Radiation therapy was recommended. After consultation with Dr. Louis H. Weiland, a specialist in head and neck pathology, Dr. Foote concluded that the veteran had a high grade mucoepidermoid carcinoma. Medical reports from the University of Florida College of Medicine reflect postoperative treatment, including radiation therapy, for recurrent mucoepidermoid carcinoma of the left parotid, from November 1988 to March 1989. Among those records is a November 1988 report of James T. Parsons, M.D., which notes that review of pathology by Dr. Pierson revealed a poorly differentiated tumor, consistent with mucoepidermoid carcinoma. Another report of Dr. Parsons, dated in January 1989, indicates that the veteran still had persistent firm induration in the left low sternocleidomastoid muscle which was most consistent with extensive tumor involvement. That finding, in conjunction with a poor response or possible progression of the disease, led those treating the veteran to believe that there was little or no likelihood of cure. A medical certificate signed by John E. Woods, M.D., indicates that he examined the veteran in October 1988 for a large left infratemporal mass. A history of temporomandibular joint pain in June 1988, was noted. The certificate also details the aforementioned October 1988 neck surgery. Dr. Woods noted that the veteran was doing satisfactorily when last examined on October 25, 1988; however, he later learned that the veteran had died from respiratory embarrassment secondary to tumor displacement of the trachea. Dr. Woods reported that, prior to coming to the Mayo Clinic, the veteran obviously had this disorder for a long time. An undated medical certificate signed by Dr. Parsons indicates that the diagnosis made after the veteran's death was mucoepidermoid carcinoma of the parotid, with extensive involvement in the left sternocleidomastoid area, left posterior strip, and supraclavicular fossa extension. Dr. Parsons noted that original symptoms, by history, were evident in December 1987. In a March 1990 letter, Ian T. Jackson, M.D. reports that he had examined the veteran in October 1988. Clinical evaluation revealed a mass in the veteran's neck just at the angle of the mandible, with associated trismus. X-ray examination revealed involvement in the infratemporal fossa. At the time of the veteran's October 1988 surgery, the tumor was "very large" (5 x 5 x 3 centimeters) in size, and located in the lateral wall of the pharynx and in the infratemporal fossa. According to Dr. Jackson, it was difficult to say how long the mass had been present, but it could have been there for "many years." He indicated that, on a subsequent report, the lesion was classified as mucoepidermoid carcinoma with one lymph node metastasis. Dr. Jackson commented that the histological findings were suggestive of an initially slowly growing lesion which could have been present for "a number of years." He noted that he informed the appellant that it was "possible" for the tumor to have been present for more than seven years. At her April 1990 personal hearing, the appellant testified under oath that she had known the veteran for more than 20 years, and that they had been married in 1966. In those 20 years, she stated, the veteran experienced cracking and locking of the jaw on the left side, which a physician suggested was an indication that there was a problem that had been there for some time. She also stated that the veteran had bad breath for as long as she had known him, and that it became worse after service. During service, the veteran had various dental problems, including a dislocated left jaw and temporomandibular joint problems. She testified that, following military service, the veteran had ear infections of increasing frequency, his hearing diminished, his head began leaning toward the left, and his left eyebrow began drooping. He also had problems with mucus flow from his left nostril. She further testified that, at the time of the veteran's 1988 surgery, Dr. Jackson informed her that mucus problems and bad breath are associated with the type of cancer the veteran had, and that the cancer had been present for many years. She further stated that Dr. Jackson indicated that this type of cancer can remain dormant for many years and "balloon up" rapidly upon surgical intervention. In a January 1991 statement, Dr. Jackson reported that mucoepidermoid carcinoma or adenocystic carcinoma which occurs in the parotid gland and in other areas of salivary tissue, has a variable history. He explained that, although some high grade lesions can grow very quickly, many low grade lesions can be present either in the primary area or as secondary deposits for many years. He added that he has had patients who had deposits for 10 to 15 years; thus it is perfectly reasonable to believe that the veteran had a primary lesion for seven years prior to it becoming obvious. He stated that "certainly the histological appearance is very suggestive of that," and that it certainly would be "wrong to exclude this possibility" in this case. In April 1993, the Board requested an opinion from the AFIP as to the date of onset of the veteran's mucoepidermoid carcinoma. Accompanying that request were tissue slides obtained from the Mayo Clinic in 1992, and the veteran's claims folder. In a May 1993 opinion, the Assistant Chairman of the Department of Oral Pathology indicated that he had reviewed the pertinent service medical records, as well as pertinent postservice medical evidence. He concluded that: [I]t is not possible in any individual case to make precise statements. However, since the veteran presented eight years after retirement with a high grade malignancy, which typically arise[s] and progress[es] rapidly, it is unlikely that the tumor was present undetected prior to the veteran's retirement from active service. In a July 1994 letter, K. Krishnan Unni, M.B., B.S., identified himself as the pathologist who reviewed the material at the time of the veteran's October 1988 neck surgery. Dr. Unni indicated that the presence of well differentiated carcinoma suggested that the tumor had been present "for some time," and had transformed to a higher grade of malignancy. He concluded that, although it was not possible to say how long the lesion had been present, it was reasonable to conclude that it could have been present for a considerable length of time, perhaps for years. A July 1994 letter of Dr. Jackson indicates that he spoke with Dr. Unni and that Dr. Unni supported his conclusion that it was "possible" that the veteran's tumor was present during his time in the military. October 1994 correspondence from Dr. Jackson to the veteran's attorney was submitted. In it, Dr. Jackson reiterated Dr. Unni's statement that it was possible that the veteran's tumor was present during his time in the military. He added that the veteran should be given the benefit of the doubt. He agreed that high-grade mucoepidermoid carcinoma was a rapidly growing tumor in the majority of cases, although he emphasized the statement in the AFIP opinion to the effect that it was not possible in any individual case to make precise statements. November 1994 correspondence from Dr. Unni to the veteran's attorney was also submitted. He indicated that he had reviewed the AFIP opinion letter, and that it was based upon a diagnosis of high grade mucoepidermoid carcinoma. Dr. Unni reiterated that, in addition to high grade carcinoma, the veteran's neoplasm also showed lower grade or better differentiated areas; thus he believed that there was a good likelihood that the veteran's lesion had been present for several years. II. Analysis Service medical records are devoid of any findings of any type of carcinoma. The appellant argues, however, that the veteran's inservice dental problems and earaches represented early stages of the carcinoma. Unfortunately, her arguments have no clinical support. Service medical records do not reflect any complaints or symptoms that were clinically interpreted, during service or at any time thereafter, as manifestations of carcinoma. Inasmuch as the appellant is offering her own medical interpretation of the veteran's inservice symptoms, we would note that the record does not indicate that the appellant has any medical expertise. See Espiritu v. Derwinski, 2 Vet.App. 492 (1992). There is no postservice evidence which demonstrates any manifestation of carcinoma within one year following service. Indeed, according to clinical evidence of record, the veteran's carcinoma did not initially manifest until December 1987, or nearly seven years after discharge from service. None of the postservice clinical evidence of record affirmatively attributes carcinoma to the veteran's time in service. Furthermore, a finding of carcinoma nearly seven years after service does not permit a reasonable inference that the carcinoma is attributable to active service, particularly in the absence of any documented complaints or findings relating to carcinoma in that time. In fact, on the report of the veteran's November 1987 physical examination, there were no recorded complaints or findings other than of mild anemia. The Board recognizes, as stated in several medical opinions of record, that the onset of the veteran's carcinoma cannot be determined with precision. Nevertheless, under statutory and regulatory provisions, a grant of service-connection for cause of death requires probative evidence linking the veteran's fatal carcinoma to service. No such evidence is of record. The strongest postservice evidence supporting the appellant's claim is contained in various letters of Dr. Jackson. His March 1990 comment that the histological findings were suggestive of an initially slowly growing lesion which could have been present for a number of years, is insufficient to fill the seven year gap between discharge and the initial manifestations of carcinoma. After all, "a number of years" could be two, three, four or forty. Again, we recognize that specificity cannot be achieved in cases such as this. However, because service connection cannot reasonably be inferred in light of the seven year gap, an opinion must state with some reasonable degree of medical certainty that the carcinoma can be linked to service. Dr. Jackson's comment does not do so; thus we find it of limited probative value. We also recognize Dr. Jackson's March 1990 comment that it was possible for the veteran's tumor to have been present for more than seven years. Although he bridges the seven year gap, he does so with virtually no degree of medical certainty. "Possible," like "plausible," may give rise to a well-grounded claim, but it does not prove that claim. Proof is that evidence which has the power to convince the mind of the existence of a fact. 30 Am. Jur. 2d Evidence § 1080 (1967). For example, even if there is but a slim chance of the existence of a fact, that fact may nonetheless be regarded as "possible," although it would hardly be convincing of the existence of that fact. Thus, the fundamental issue in this case is not whether there is a possibility, but what the extent of that possibility is--i.e., the probability--that the veteran's carcinoma had its onset in service. While Dr. Jackson's statement is probative insofar as it states a "possible" relationship, it is of limited probative value beyond that point since it does not provide any further basis to evaluate the actual likelihood of such relationship. We further recognize Dr. Jackson's January 1991 statements that, in light of patients who have had low grade deposits from 10 to 15 years, it is perfectly reasonable to believe that the veteran had a primary lesion for seven years prior to it becoming obvious, and that the histological appearance is very suggestive of that. Although these statements appear to offer somewhat more substantive support for the appellant's claim, their import with regard to the probability of inservice incurrence is not particularly clear. In fact, we would emphasize that Dr. Jackson tempered that conclusion with the equivocal statement that it would be wrong to exclude the possibility (that the veteran had a primary lesion for seven years prior to it becoming obvious) in this case. In addition, in subsequent correspondence, Dr. Jackson's strongest statements are to the effect that it is possible that the veteran's tumor was present in service. Thus, his statements, viewed in totality, suggest nothing more than a possibility that the veteran's carcinoma is attributable to active service. As discussed previously, such statements are of limited probative value. Nor are Dr. Unni's statements any more probative. In July 1994, he stated that the veteran's tumor could have been present for a considerable length of time, perhaps for years. In November 1994, he stated that he believes that there is a good likelihood that the veteran's lesion was present for several years. Again, neither "a considerable length of time" nor "several years" can reasonably fill the seven year gap between discharge and initial manifestation. Indeed, the fact that Dr. Unni qualified "considerable length of time" with "perhaps for years" suggests that Dr. Unni considers it equally likely that the carcinoma existed only for less than one year. Consequently, we find Dr. Unni's statements to be of similarly limited probative value. Similarly, Dr. Woods' comment that, prior to coming to the Mayo Clinic, the veteran obviously had carcinoma "for a long time," does not sufficiently identify a time frame for onset of carcinoma to be probative of whether that disorder is attributable to service. Unlike the foregoing statements of Drs. Jackson, Unni and Woods, the 1993 AFIP opinion offers a more definitive statement as to the likelihood that the veteran's tumor had its onset during his military service. The AFIP opinion indicates that, since the veteran presented eight years after retirement with a high grade malignancy, which typically arises and progresses rapidly, it is unlikely that the tumor was present undetected prior to the veteran's retirement from active service. We accord substantial probative weight to that opinion, as it is the most definitive on file, and because it is supported by consideration of tissue samples and the veteran's inservice and postservice medical history. We would add that the evidence does not indicate whether Drs. Jackson, Unni or Wood ever reviewed the veteran's inservice medical history. We note that a November 1994 statement of Dr. Unni could be construed as a challenge to the AFIP opinion. Dr. Unni stated that the AFIP opinion was based upon a diagnosis involving high grade mucoepidermoid carcinoma, whereas Dr. Unni found that, in addition to high grade carcinoma, the veteran's neoplasm also showed lower grade or better differentiated areas. That finding led Dr. Unni to believe that there is a good likelihood that the veteran's lesion had been present for several years. We find that challenge to be of limited significance. We would first emphasize that the AFIP reviewed more than just a written diagnosis of high grade mucoepidermoid carcinoma--it had access to the same tissue slides that were available to Dr. Unni, and therefore the opportunity to make an independent assessment as to the time of onset of the veteran's carcinoma. There is no evidence, other than Dr. Unni's differing interpretation, to suggest that the absence of an AFIP finding of low-grade carcinoma was based upon erroneous information or a faulty medical premise. Indeed, several physicians of record--Drs. Foote, Wieland and Pierson-- related diagnoses which indicate high grade carcinoma, but did not include low grade carcinoma. In addition, we would note that Dr. Unni's November 1994 conclusion--that there is a good likelihood that the veteran's lesion had been present for several years--is not necessarily at odds with the AFIP opinion. Even though Dr. Unni found traces of low grade carcinoma, he could only express the likelihood that it was present for several years, which does not compel the conclusion that it was present in service. Accordingly, the Board finds that the AFIP opinion is the most probative of record. We have considered the appellant's testimony concerning the veteran's inservice and postservice symptoms, and we find her testimony to be sincere. However, for reasons discussed below, we do not find her testimony to be probative of whether the veteran's carcinoma is attributable to active military service. She testified that, during service and thereafter, the veteran experienced cracking and locking of the jaw on the left side, which a physician suggested was an indication that there was a problem that had been there for some time. The record contains some support for her testimony. The report of the veteran's retirement examination shows that the veteran was discharged with bilateral mandibular exostosis of the lingular aspect, and temporomandibular problems are documented as early as May 1988. Nevertheless, service medical records are negative for cracking or locking of the jaw, and the report of the veteran's November 1987 physical examination reflects no complaints, history or findings of jaw cracking or locking, or of any other similar symptoms. Furthermore, assuming that a physician did suggest that the cracking and locking of the left jaw were an indication that there was a problem that had been there for some time, the fact that the problem may have been there "for some time" does not necessarily link it to active service. Thus, in light of the clinical evidence of record, we do not find that testimony to be probative. Also at her hearing, the appellant stated that the veteran had ear infections in service, that they became worse after service, and that the veteran had various dental problems during service, including a dislocated left jaw and temporomandibular joint problems. She further testified that he also had problems with mucus flow from his left nostril. Although service medical records reflect dental treatment, treatment for upper respiratory tract infections manifested partly by mucus flow, and complaints of ear infections, the record is devoid of any clinical evidence linking the veteran's carcinoma to any of those inservice problems. Again, in light of the clinical evidence of record, we do not find the appellant's testimony to be probative. She further testified that, at the time of the veteran's 1988 surgery, Dr. Jackson informed her that mucus problems and bad breath are associated with the type of cancer the veteran had, that the cancer had been present for many years, and that this type of cancer can remain dormant for many years and "balloon up" rapidly upon surgical intervention. The record does contain supporting documentation regarding Dr. Jackson's statements that the cancer was present for years. However, as discussed previously, the statement that the cancer was present for years does not necessarily fill the seven year gap between discharge and the initial manifestations of the carcinoma. Moreover, the record contains no documentation indicating that the presence of mucus problems or bad breath are indicative of a longstanding carcinoma. Accordingly, we do not find that testimony to be probative. We have also considered a copy of an article from a medical text relating to the epidemiology of head and neck cancer, submitted in support of the appellant's claim. The article discusses the natural history of squamous cell carcinoma, but does not discuss the length of time it typically takes for that type of cancer to develop. We therefore find it of no probative value. We would note that the record contains 1988 and 1989 treatment records from an Air Force hospital, some of which contain discussion relating to the veteran's carcinoma. None of those records provide any additional support for, or insight into, any factual determinations at issue in this case. As a final matter, we have considered whether the appellant is entitled to the benefit of the doubt. Under 38 U.S.C.A. § 5107(b) (West 1991), when there exists an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the claimant in resolving that issue. See also 38 C.F.R. § 3.102 (1993). The Board recognizes the appellant's sincere belief that the carcinoma which caused the veteran's death should be attributed to service. It is clear that she has expended considerable effort in her attempt to assemble the requisite documentation to substantiate her claim. Nevertheless, even viewed in its strongest light, the evidence submitted in support of the appellant's claim stands only for the proposition that there is a possibility that the fatal carcinoma was present as early as the veteran's period of service. Because it does not establish any degree of probability beyond mere possibility, the Board must find that the evidence against the appellant's claim, including the opinion of the AFIP, clearly outweighs that in favor of the claim. Thus, while we have given sympathetic consideration to the appellant's claim, the Board finds that a preponderance of the evidence is against a finding of service connection for the cause of the veteran's death. There exists no approximate balance of positive and negative evidence requiring resolution of any doubt. ORDER Service connection for the cause of the veteran's death is denied. J. J. SCHULE D. C. SPICKLER N. R. ROBIN U. R. POWELL B. B. COPELAND S. L. WILKINS NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.