BVA9504203 DOCKET NO. 92-11 924 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUE Entitlement to service connection for fibrocystic disease of the breasts. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran in this case had active service from July 1971 to November 1973 and from February 1979 to February 1983, with additional periods of active duty for training in the United States Air Force Reserve. This appeal to the Board of Veterans' Appeals (Board) arises from a September 1989 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In July 1992, a hearing was held in Lincoln, Nebraska, before a traveling member of the Board. A transcript of that hearing is included in the veteran's claims folder. In March 1993, the veteran's case was remanded to the RO for additional development. Such development having been accomplished, the case is now returned to the Board for further appellate review. The issue in this case has previously been characterized as whether new and material evidence has been submitted sufficient to reopen a claim of entitlement to service connection for fibrocystic disease of the breasts. In that regard, while in a rating decision of May 1984 the RO denied entitlement to service connection for bilateral fibrocystic disease of the breasts, it would appear that the veteran was never informed of that decision. Accordingly, the May 1984 rating decision is not final as to this issue, and service connection for fibrocystic disease of the breasts will be considered on a de novo basis. CONTENTIONS OF APPELLANT ON APPEAL The veteran's argument is that the RO committed error in denying entitlement to service connection for fibrocystic disease of the breasts in that such disability had its origin during the veteran's active military service. In the alternative, it is contended that the veteran's current fibrocystic disease of the breasts is the result of medication prescribed for service- connected endometriosis with a history of vaginitis, and postoperative residuals of a total abdominal hysterectomy and salpingo-oophorectomy. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the veteran's claims file, and for the following reasons and bases, it is the decision of the Board that a preponderance of the evidence is against the claim for service connection for fibrocystic disease of the breasts. FINDINGS OF FACT 1. The veteran's fibrocystic disease of the breasts clearly preexisted service entrance. 2. It is not shown that during service there was an increase in the severity of the veteran's preexisting fibrocystic disease of the breasts beyond that to be expected in the natural progress of the disease. 3. Service connection is currently in effect for endometriosis, with a history of vaginitis, and postoperative residuals of a total abdominal hysterectomy and salpingo-oophorectomy. 4. Fibrocystic disease of the breasts is not shown to be causally related to medication prescribed for service-connected endometriosis, with a history of vaginitis, and postoperative residuals of a total abdominal hysterectomy and salpingo- oophorectomy. CONCLUSIONS OF LAW 1. The veteran's fibrocystic disease of the breasts clearly and unmistakably preexisted service, and the presumption of soundness on entry in service is rebutted with respect to this disorder. 38 U.S.C.A. §§ 1111, 1137, 5107(b) (West 1991); 38 C.F.R. § 3.102 (1994). 2. Fibrocystic disease of the breasts was not incurred in active military service; nor is it shown that the veteran's preexisting fibrocystic disease was aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1153, 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 3.306 (1994). 3. Fibrocystic disease of the breasts is not proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 3.310(a) (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS At the outset, the Board has found that the veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a) (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. In that regard, the Board notes that, in March 1993, the case was remanded to the RO for an additional VA examination in order to more accurately determine the exact nature and etiology of the veteran's fibrocystic disease of the breasts. In addition, all sources of medical or other evidence identified by the veteran have now been pursued by the RO. No further assistance to the veteran is required in order to comply with the duty to assist her mandated by 38 U.S.C.A. § 5107(a) (West 1991). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991). As regards a preexisting injury or disease, such injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to natural progress of the disease. Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where a preservice disability underwent an increase in severity during wartime service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. As to peacetime military service, the specific finding requirement that an increase in disability during such service is due to natural progress of the condition will be met where the available evidence of a nature generally acceptable as competent shows that the increase in severity of a disease or injury or acceleration in progress was that normally to be expected by reason of the inherent character of the condition, aside from any extraneous or contributing cause or influence peculiar to military service. Consideration must be given to the circumstances, conditions, and hardships of service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306 (1994). Finally, where a veteran served during a period of war or during peacetime service after December 31, 1946, that veteran is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that a disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. §§ 1111, 1137 (West 1991). The veteran's initial service entrance examination of December 1970 was essentially unremarkable. No disease or disorder of the breasts was in evidence. On numerous occasions during the veteran's periods of active military service, she received treatment for a myriad of gynecologic complaints, among them breast tenderness and discharge. In December 1983, approximately 10 months following her final discharge from service, she was found to have a questionable breast mass. Shortly thereafter, in February 1984, the veteran received a diagnosis of fibrocystic breast disease. In January 1988, the veteran underwent a total abdominal hysterectomy, following which she was placed on estrogen and progesterone for prevention of premature coronary artery disease, hip fractures, and osteoporosis. In a statement of June 1989, S. Jochen-Stoehr, R.N., C.N.P., and F. Gawecki, M.D., wrote that one side effect of the veteran's hormonal therapy was mastodynia, and aggravation of the fibrocystic changes in her breasts. In subsequent correspondence of mid-March 1993, S. Jochens [sic], R.N., C.N.P., wrote that the benefits and symptomatic relief derived from the veteran's hormonal replacement therapy had, apparently, been enough to warrant their usage in order to sustain her quality of life, even though there might be a "side effect of increasing symptoms with...fibrocystic changes." In late March 1993, the veteran underwent bilateral reduction mammoplasty for long-standing neck, back, and shoulder pain related to macromastia. It was noted at that time that the veteran was symptomatic not only for fibrocystic breast disease, but for macromastia. It was felt that a large portion of the veteran's breast pain was related to this macromastia, and that, by performing reduction mammoplasty, it would be possible to reduce the volume of breast tissue susceptible to fibrocystic disease and, in so doing, substantially reduce her pain. On VA gynecologic examination in July 1993, it was noted that the veteran's fibrocystic disease was not caused by estrogen replacement therapy and progesterone. According to the examining gynecologist, the veteran required estrogen and progesterone since, following hysterectomy, she was postmenopausal and, consequently, had no endogenous (hormone) production of her own. In October 1994, due to the complex medical questions in this case, the Board sought the opinion of an independent medical expert. The consulting physician was to comment as to the probability that the veteran's fibrocystic breast disease, first detected in December 1983, and confirmed in February 1984, originated during her active military service. In a letter dated in November 1994, C. Hammond, M.D., of the Duke University Medical Center, wrote that he had reviewed the veteran's records "in detail" and that such records indicated that, for a number of years prior to her entry into service, the veteran had experienced problems with galactorrhea (that is, the excessive or spontaneous flow of milk from the breasts irrespective of nursing). Painful breasts and nipple discharge had been reported on one occasion in service, though not on a chronic basis, and with nonspecific symptomatology. In the opinion of Dr. Hammond, the veteran's fibrocystic breast change began in adolescence following puberty, and was manifest as a clinical syndrome several years antecedent to her first entry into service in 1973. It "progressed as one would likely expect," and was formally diagnosed on mammography and examination in December 1983, 10 months following the veteran's discharge from service. This was confirmed by biopsy in February 1984, with exacerbation since a hysterectomy in January 1988, and treatment with Estrogen. Dr. Hammond commented in summary, that the veteran's fibrocystic breast change began antecedent to her entry into service, and was not likely service related, "nor originating after her entry into the service. It did progress while she was in service, but one would expect that to occur in any woman with it, regardless of occupation." A copy of this opinion was provided to the veteran's representative, who forwarded it to the veteran. No further argument or evidence was presented. The clinical data of record and the independent medical expert opinion clearly establish that the veteran's fibrocystic breast disease preexisted her entry upon active service. The presumption of soundness upon service entrance is, therefore, effectively rebutted. Preexisting breast disease underwent no increase in severity beyond natural progress during the veteran's active service. Since, post hysterectomy hormone therapy began after the fibrocystic breast disease had long been present, while possibly exacerbating the veteran's already existent breast disease, it can in no way be held to be a causative factor in the development of that disease. Consequently, the veteran's arguments as to the origin and etiology of her fibrocystic breast disease are not persuasive and must fail. In reaching the above determination, we have given due consideration to the veteran's testimony at a hearing before a member of the Board in July 1992. Such testimony, while informative as to the veteran's beliefs, arguments, and recollection of sequence of events, is not probative as to the matter at hand. The testimony does alter the balance of the weight of the evidence, the preponderance of which is clearly against the veteran's claim. We do not doubt the sincerity of the veteran's statements. However, she is not trained in medicine, and, as a layperson, is not competent to provide an expert opinion regarding the etiology of the claimed disorder. ORDER Service connection for fibrocystic disease of the breasts is denied. GEORGE R. SENYK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. (CONTINUED ON NEXT PAGE) 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.