CCF Veterans Project
A Note About This Research
This information has not been put together by an attorney and does not constitute legal advice. The following research may be used in filing your claim.
I have limited the amount of research due to the fact the VA has discouraged a lot of paperwork, since they are electronically filing. However, be aware that more research is available. Most of it says the same thing, but if the VA requests more articles concerning these subjects, they are available.
Since filing procedures and various requirements may change, it is strongly suggested to contact one of the National Service Organizations such as the Disabled American Veterans, Veterans of Foreign Wars, American Legion, Vietnam Veterans of America, Paralyzed Veterans of America, as well as State Departments of Veterans Affairs or Veterans Commissions and County Veteran Service Officers. The assistance is free. You can get their telephone numbers for your local regional office online by listing the organization and the city and state you are going to file.
Although, there are many fine Service Officers, all are not the same as far as knowledge, experience, and commitment. Make an appointment to see if you are comfortable with whomever you choose to represent you. It is helpful if they are familiar with Cholangiocarcinoma. If they are not familiar with it, it does not mean they are not qualified. This is a rare cancer and many do not know about it. Many times you have to educate the Service Officers. However, make sure they are willing to listen and do what is necessary to get the claim approved. In some instances, veterans were turned down, because the Service Officer had no knowledge of this disease or were not aware that a claim could be filed. The VA recently added information about this cancer and the liver fluke online. Hopefully, they have made the Service Officers aware of it. Remember, although they may be helping you, you have to be your own advocate.
The Service Officer will tell you what information you need to file. Always have your DD214. If possible, it is good to get the medical records of the Veteran and any private providers that have treated the veteran. Although, the Service Officers can get them for you by you signing a release, it is better to get them yourself. This way you can keep track of the provider. If you wait for a Service Officer to check on all this, or if there is a problem with cost, this may delay the process.
You do not have to have all the medical records to make an appointment with the Service Officer. It is important that you see them first; they will file a document called, Intent to file. This would be the effective date when the claim is approved. Remember do not put off seeing a Service Officer because you do not have all the information. It is important to see them as soon as you are able.
A medical opinion or Nexus is very important to the claim. The Nexus letter is explained in detail in a separate section.
REMEMBER TO KEEP COPIES OF EVERYTHING. KEEP THE ORIGINAL DOCUMENTS AND GIVE THE VA COPIES, THE REASON BEING, IF DOCUMENTS GET LOST, ETC., YOU WILL HAVE THE ORIGINAL DOCUMENT.
The following link is an overview of the process:
- The following article is on the va.gov website. It advises Vietnam Veterans and other veterans that served in areas where the liver flukes are endemic to be aware of the connection of this cancer with the exposure to liver flukes.
- For those Vietnam Veterans who have been diagnosed with diabetes due to Agent Orange, take note that it can also be a risk factor for this cancer.
- Although, the VA states it is not aware of any studies that show Cholangiocarcinoma occurs more often in Vietnam War Veterans than other groups that does not change the fact that Vietnam Veterans have been exposed to more risk factors than the general population, which include exposure to liver flukes and dioxin.
- This article can be included in your claim because the VA acknowledges that liver flukes are in Vietnam, and it is a risk factor for Cholangiocarcinoma.
- For those veterans who are diabetic due to Agent Orange, this article should be included since it states that diabetes is a risk factor.
- Due to the fact, this information is on the website, you shouldn’t need any other articles to reiterate this fact.
- Bile Duct Cancer (Cholangiocarcinoma) and Liver Fluke Infection – Public Health
- The following two articles will show that in most cases, exposure to liver flukes will not cause symptoms and is usually asymptomatic.
- On almost every claim that has been denied, the VA will state it is denied due to the fact the veteran did not show symptoms in the service or within one year following discharge.
- The following articles show that both parasites Clonorchis sinensis and Opisthorchis viverrini are usually asymptomatic, making the reasons for a denial by the VA invalid.
- In the articles, these facts are highlighted in yellow.
- WHO _ Clonorchiasis
- World Journal of Gastroenterology
- The veterans were given a book when they were sent to Vietnam. The book was called A Pocket Guide to Vietnam. The book has information regarding the Vietnamese culture, how a soldier should act, what foods to eat, and what foods to avoid, etc. One page of the book is entitled, “The Fish is Good.”
- Many veterans have discussed the fact, due to this book, and due to the fact they were afraid to eat any other Vietnamese dish, they would only eat fish. This book basically gave the veteran the go ahead that it was okay to eat the fish.
- Although, the primary way of being exposed to liver flukes is ingestion of undercooked, raw, and fermented or pickled fish, there are cases where people have been diagnosed with the liver flukes, but never ate fish.
- If food is prepared in unsanitary conditions where the same utensils or cutting board are used during preparation without cleaning them, a person could be exposed to the parasite due to improper sanitation.
The following two articles show that dioxin has been correlated with an increased risk for Cholangiocarcinoma.
In both articles, the statements regarding this fact are highlighted in yellow.
According to the Department of Veteran Affairs, veterans who served in Vietnam, Korea DMZ, Thailand, who flew or worked on C-123 Airplanes, are eligible for Agent Orange Health Registry Exam. Veterans may have been exposed in other areas to Agent Orange and more information on this and the areas and time frames of service recognized by the VA can be located at:
The writer of the Nexus letter must be an expert. This is most often a medical doctor who treated the veteran. If cancer is the condition, an oncologist is preferred. However, there have been cases approved where a family doctor, gastroenterologist, or hepatologist were involved.
The expert who signs your nexus letter must have thoroughly reviewed all available and pertinent medical records and state that fact in the letter.
When writing a nexus letter, a few points to remember are in order. The letter should be as brief as possible while stating facts. The doctor who writes your letter does not have to use absolutes or conclusions in his or her statements. Opinions are made based on conjecture of observing facts and possibilities arising from those facts.
This means that the doctor isn’t required to say that one thing definitely caused another, only that it as least likely than not or more likely than not to have led from point A to point B. (MAKE SURE YOUR DOCTOR IS AWARE THAT IT DOES NOT HAVE TO BE DEFINITIVE. MOST DOCTORS WANT SOMETHING THAT IS CERTAIN. THIS IS NOT NECESSARY. THEY ONLY HAVE TO SHOW THAT DUE TO THE CIRCUMSTANCES IT IS AT LEAST LIKELY OR NOT, OR MORE LIKELY THAN NOT).
The preferred language to describe an expert’s opinion should express whether it is more likely than not (i.e., probability greater than 50 percent), or at least as likely as not (i.e., probability of 50 percent)
A complete rationale for all opinions should be expressed. For example, your doctor should point out that you have no known risk factors that might have otherwise precipitated your condition. This leads to the conclusion that your known exposure to liver flukes and dioxin has caused this cancer. The clinical nexus is then established. There was causation in military service, and the effect today, is being diagnosed with Cholangiocarcinoma
In determining whether service connection is warranted, the VA is responsible for considering evidence both for and against the claim. If the evidence, as a whole, supports the claim or is about evenly balanced, the veteran prevails. If the preponderance of the evidence is against the claim, then it is denied.
Your Name, address, etc.
To Whom It May Concern;
I am (Doctor’s Name). (Veteran’s name) is a patient under my care since (Date) (Veteran’s name) diagnosis is Cholangiocarcinoma.
I have personally reviewed his medical history and (Veteran’s name) has no other known risk factors that may have caused his diagnosis.
In reviewing the medical literature, it states that exposure to liver flukes and dioxin puts the veteran at a higher risk to develop this cancer.
It is my opinion that it is more likely than not that (Veteran’s name) has developed this cancer due to his or her exposure to liver flukes and dioxin while (her or she) was serving in Vietnam.
*If the veteran is diabetic and it is related to Agent Orange exposure, it should also be added as a risk factor, since it is also a cause, as noted, on the VA website.
The nexus letter should be as detailed and complete as your circumstances dictate.
Many physicians, both civilian and VA doctors are reluctant to write such a letter. Sometimes, they are busy or are concerned the VA will contact them. I have never seen that happen, not to say that it doesn’t, but it is rare for the doctors to be contacted. The physicians also have a problem, as mentioned previously, in thinking in terms of certainty. With the VA claim, it does not have to be certain. It only has to show that it is at least likely or more likely than not that the veteran’s diagnosis is due to his or her service in Vietnam due to the risk factors, he or she was exposed to.
Many times the physician is most often simply too busy to write such letters or isn’t sure of the proper statements to make.
It is recommend that you write the letter for your doctor. If you elect to do this you must carefully construct every word to ensure that there is nothing in the letter that the doctor could disagree with. Keeping it simple is most likely to lead to your doctor signing the letter. (REMEMBER WORDING IS IMPORTANT: STATING IT IS MORE LIKELY THAN NOT MEANS THAT THERE IS MORE THAN 50% CHANCE. STATING IT AS LEAST LIKELY OR NOT MEANS IT IS A 50% CHANCE. Both of these statements favor the veteran. But, if you can use the words,” More likely than not,” it is better.
Your best bet to have your doctor agree with you and write the letter onto his letterhead is to approach him or her directly. Don’t hand it off to a receptionist or nurse to do it for you. It would be a good idea to make an appointment, bring the research, and samples of letters.
The VA generally requires the veteran to show some kind of proof they could have been exposed to the risk factors that cause Cholangiocarcinoma, such as the liver flukes and/or Dixon, which is in Agent Orange. If the veteran has any documents, papers, photos, letters from other veterans, this will help in the claim. It is suggested to go through an organization that will know exactly what is needed to help with the claim. The following links may aid you in establishing if your ship was one that was exposed to Agent Orange. Also, ask the Service Officer who may be helping you with the claim how to go about finding necessary information. It Is wise to also send for your service records, which may have more detailed information.
- http://publichealth.va.gov/exposures/agentorange/shiplist/list.aspU.S. Navy and Coast Guard ships that operated in Vietnam: https://www.benefits.va.gov/compensation/docs/shiplist.docx
The following articles do not have to be included in the claim, but it is good for the veteran to have knowledge of it. It includes The Benefit of Doubt Theory, how it applies to claims, and the reason the Agent Orange Studies are flawed. If one is denied due to the VA stating it is not in the Agent Orange Studies, the article points out why that is the case.
The Benefit of Doubt Rule states: When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. (See 38 U.S.C. § 5107(b); see 38 C.F.R. § 3.102 (2016). The term used in the law to describe this balance of facts is “equipoise). A veteran must merely show a 50-50 chance.
The benefit of doubt rule also applies to medical and scientific concepts. There is no requirement by law that all health care providers accept a theory or argument. The law mandates only that evidence be in equal on both sides to give the benefit of the doubt to the veteran. It does not require a consensus of scientific support. Thus the wording, as explained in the nexus opinion, “at least likely than not,” or “more likely than not” will favor the veteran when the VA decides the evidence is 50-50 balanced. If the evidence is close and there is a balance between positive and negative evidence, the tie goes in favor of the veteran.
The Court has held that the failure of the BVA to apply the benefit of the doubt rule or to set forth clearly its reasons for not applying it constitutes error. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Sussex v. Derwinski, 1 Vet. App. 526, 529 (1991). In addition, the Court notes that 38 U.S.C. 1154(b) provides specifically that the Secretary “shall resolve every reasonable doubt in favor of the veteran.” 38 C.F.R. § 3.302.
Furthermore, when the BVA can cite no evidence or facts by which to impeach or contradict a claim, there is no justifiable basis upon which to deny application of the doctrine under 38 C.F.R. § 3.102. Sheets v. Derwinski, 2 Vet. App. 512, 516-17 (1992).
Because the benefit of the doubt rule only applies in these specific situations, in cases where there is significant evidence in support of a claim, however, VA must provide a satisfactory explanation as to why the evidence was not balanced enough to apply the rule if the decision was adverse to the claimant.
The failure of the Agent Orange Studies In regard to studying Cholangiocarcioma
Due to Cholangiocarcinoma being a rare cancer, the studies done by the National Academy of Sciences (NAS) are insufficient to determine the rate this cancer is affecting Vietnam Veterans. In speaking with an official with the Vietnam Agent Orange Studies, he conveyed, with rare cancers such as Cholangiocarcinoma, it takes something other than scientific review to determine the results of Agent Orange in connection with this cancer.
This premise is also mentioned in the Agent Orange Studies. I am citing two examples from 1994 and 2014.
“ ……Second, some cancers are sufficiently rare that even among all Vietnam veterans, there will be too few cases for reliable epidemiologic studies. This problem of inadequate numbers of cancer cases were also seen in the Centers for Disease Control’s (CDC) Selected Cancers Study; even with a network of cancer registries that covered 10 percent of the U.S. male population, born between 1921 and 1953, the statistical power to detect an association between some of the cancers under study and Vietnam service was low.”
“Rare diseases…………..are difficult to study, because it is difficult to accumulate enough cases to permit analysis. Often, the result is that the observed cases are included in a broader, less specific category. Thus, epidemiologic data may not be available for assessing whether a particular rare disease is associcate with Agent Orange exposure.”
In other literature, it lists problems with misdiagnoses and miscoding regarding Cholangiocarcinoma. At times it is incorrectly miscoded or coded to be where the cancer metastasized, such as liver cancer, instead of where it originated. This adds to not being able to get an accurate count, which results in the Agent Orange Study as related to this cancer being flawed. It makes their conclusion; there are not enough Vietnam veterans who have this cancer to make it presumptive, invalid.
In the following article, it states the confusion in coding as to why there is a problem in accurate data regarding Cholangiocarcinoma:
Biliary tract cancers: epidemiology, molecular pathogenesis and genetic risk associations
Differences in the methods of classification of BTC can lead to misleading or erroneous epidemiological data (14). Changes in the classification codes over time also confound the interpretation of the available epidemiological data. Thus, epidemiologic studies on the BTC must be interpreted with caution (14). Overall, considering all three types of bile duct cancer, iCCA and pCCA each appear to comprise about 40% of CCA, while dCCA comprise the remaining 20%. 
As a result, of all these factors, the VA cannot make a misleading statement that because the cancer is not on their list of approved cancers, it does not affect Vietnam Veterans at the same rate as other groups. The fact is that due to inaccurate data, there is not sufficient evidence for them to disprove it. Therefore, in all cases the decision should be made according to the benefit of doubt theory and err on the side of the veteran. The Vietnam Veterans were exposed to more risk factors for this cancer than the general population, which include exposure to dioxin and liver flukes.
When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.
See 38 U.S.C. § 5107(b); see 38 C.F.R. § 3.102 (2016). The term used in the law to describe this balance of facts is “equipoise.”
 Agent Orange Study 1994, page 440
 Agent Orange Study 2014, page 41
 Lorena Marcano-Bonilla1,2,3,4, Essa A. Mohamed1,2,3, Taofic Mounajjed5, Lewis R. Roberts1,31Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA; 2Mayo Graduate School, Mayo Clinic, Rochester, MN, USA; 3Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA; 4University of Puerto Rico School of Medicine, San Juan, Puerto Rico; 5Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
The first two claims are regarding Agent Orange /Herbicide Exposure. The first case listed, Citation Nr: 0201281, was approved due to the veteran being in an area where there were Agent Orange missions and operations were performed.
The second case, Citation Nr :0740247 was approved due to a physician’s opinion who stated the veteran had various cancers during his life which he felt was due to herbicides in Vietnam. It was granted on herbicide exposure.
The third claim, Citation Nr: 1401793 was granted both due to herbicide exposure and liver flukes. A VA physician in her opinion stated the parasites are endemic in Vietnam. The Board of Veterans Appeals granted the approval on bot the liver fluke and herbicide exposure.
The remaining claims are on Liver Fluke exposure. Most cases as the preceding three have been approved due to “The Reasonable Doubt Theory.”
You may use these files to go with your claim. The VA will state that each claim is decided on an individual basis, and they do not give weight to other veteran’s claims. However, in one of the decisions, it mentioned another approved claim. And, in my case, it was approved due to research, doctor’s letter, and the BVA specifically stated, it was due to a letter from Sheila Harrison, the widow who made the first connection between liver fluke exposure and Cholangiocarcinoma. She had the first approved case.
These are not the only claims for Cholangiocarcinoma. There is no way of knowing how many claims were initiated or approved. These do include all the claims that people decided not to pursue, have been appealed and denied, and are still in appeal.