Chronic Errors Uncovered in V.A. Hospital Cancer Unit
An investigation into the cancer unit at Veterans Affairs Medical Center, a Veterans Affairs hospital in Philadelphia, found that doctors botched treatments for many prostate cancer patients. The New York Times reported that during a six year period, 92 of 116 surgeries to treat prostate cancer were performed incorrectly. Of these, 57 patients received too little radiation to treat their cancer and 35 received an overdose of radiation to other parts of the body. While none of these medical errors appears to have caused any patient deaths, they have led to health problems and complications for some veterans.
All of the medical errors occurred during brachytherapy, a treatment for prostate cancer that involves using a needle to permanently implant radioactive “seeds” – small metal pellets – into the prostate. These seeds then form a localized radioactive cloud which kills the cancer cells. The procedure has the advantage of treating the cancer without requiring invasive surgery. The V.A. hospital began their brachytherapy program in 2002 by hiring consultants from The University of Pennsylvania School of Medicine to perform the procedures.
Lack of Oversight
Many of the medical errors involved surgical mistakes whereby seeds were injected into the wrong organ. Others involved veterans receiving too little radiation, in part because the machine that measures whether patients received the proper dose was broken for more than a year. Lack of proper oversight by Veterans Affairs, the Joint Commission, (which accredited the hospital), and the Nuclear Regulatory Commission (NRC), which monitors the use of all nuclear materials, prevented the medical errors from being uncovered earlier. The problems were not found until spring 2008, when it was discovered that a hospital official had mistakenly ordered lower-strength seeds for an operation. This led to a closer examination of other brachytherapy procedures at the hospital and the discovery of numerous mistakes.
Impact on Patients
Radiation is a carcinogen that can damage healthy tissue in addition to destroying cancer cells. Some patients experienced severe side effects from the botched medical treatment, and several needed to have the procedure performed a second time. One veteran, Rev. Ricardo Flippin, told the New York Times that he experienced weight loss and severe bowel pain after undergoing brachytherapy at the hospital. Flippin needed surgery to repair his rectum, which had been damaged by radiation.
After the problems were discovered in mid-2008 by the NRC, the hospital suspended its brachytherapy program. Veterans Affairs has halted brachytherapy programs at hospitals in Mississippi and Ohio, although neither had as many problems as the Philadelphia hospital. The NRC has not yet concluded its investigation, and more errors may be uncovered in the future.