Possible radiation treatment problem at Penn reported

Penn's head of radiation oncology Steven M. Hahn (center) testified on Philadelphia VA's cancer care problems before U.S. House panel in July, 2009. Michael R. Bieda (right) and Gary D. Kao (left) also testified.

The University of Pennsylvania reported a possible error involving the treatment of a man for prostate cancer with tiny radioactive seeds. On January 21, the patient underwent a prostate brachytherapy procedure at Penn to implant 65 seeds under continuous ultrasound guidance, so-called real-time dosimetry.

When the patient returned to the Penn hospital for a follow-up scan on February 23, the radiation oncologists at Penn saw that the seeds were “outside the intended target.”

Penn radiation oncologists and medical physicists ran the Philadelphia VA Medical Center’s troubled prostate brachytherapy program from February 2002 until it was shut down in June 2008. During that period 97 veterans received incorrect radiation doses from seed implants. At least 31 men or their wives have filed claims for $58 million against the Department of Veterans Affairs.

Penn reported the possible medical event to the Pennsylvania Department of Environmental Protection, which oversees the medical use of radioactive materials in the state on behalf of the U.S. Nuclear Regulatory Commission.

The NRC posted the report of the event on its website today. That report notes that a “medical event may indicate potential problems in a medical facility’s use of radioactive materials. It does not necessarily result in harm to the patient.”

As a result of the problems at the Philadelphia VA, the prostate brachytherapy program is being reviewed by federal regulators. The Philadelphia VA faces sanctions from the NRC for eight violations of regulations on the medical use of radioactive materials. The NRC’s enforcement action is expected to be released later this month.

In addition, the VA’s inspector general is investigating the problems in the Philadelphia VA and across the VA’s nationwide system of hospitals. The results of that report are not expected to be released until next month.

Check out some of our stories on the problems at the Philadelphia VA here:

June 21, 2009 Sunday 
Feds see wider woes in VA's cancer errors

July 19, 2009 Sunday 
VA radiation errors laid to offline computer

July 23, 2009 Thursday 
Federal official quantifies Phila. VA problems

August 9, 2009 Sunday 
VA's prostate treatment woes began at Penn;
Prior to the VA program, leading brachytherapists said the Penn doctors performing the radioactive seed implants lacked the proper skills and safeguards.

November 15, 2009 Sunday 
VA clinic troubles bring few penalties;
Despite poor care in the Phila. prostate program, the agency has only slapped a few hands.

November 18, 2009 Wednesday 
NRC cites VA clinic for radioactive-treatment violations

November 25, 2009 Wednesday 
Claims against Phila. VA up to $58 million

December 18, 2009 Friday 
VA apologizes but denies radiation violations

January 16, 2010 Saturday 
VA clinic now concedes violations