Slow response to flawed cancer program

Gary Kao, the University of Pennsylvania radiation oncologist who directed the prostate program, appearingat a Senate hearing in June. At right is Gerald Cross of the Veterans Health Administration. (APRIL SAUL / Staff Photographer)


The slow reaction by the Department of Veterans Affairs to a flawed cancer-treatment program in Philadelphia suggests an agency that would rather forget its mistakes than learn from them.
Problems in treating nearly 100 veterans with prostate cancer began with the earliest cases, in 2002, The Inquirer has reported. But seven years later, and more than a year after this newspaper uncovered the substandard care, the VA and other institutions involved in the program have done little to hold anyone accountable.
The University of Pennsylvania doctor who performed most of the faulty procedures, Gary Kao, lost his job when the Philadelphia VA Medical Center shut down the program in June 2008. He’s on leave from his research position at Penn. Another doctor agreed to a three-day suspension.
And that’s about it for penalties to date. It’s a disappointing statement about the absence of oversight and responsibility by the VA, the university, and others.
A total of 98 veterans with prostate cancer were treated in the program, using a procedure called brachytherapy. The treatment involves placing radioactive seeds in the prostate gland to kill cancerous cells.
The procedure works well when done correctly. But veterans treated at the Philadelphia VA received incorrect doses of radiation, often because the seeds were implanted in the wrong locations.
Eight veterans have been sent to Seattle for further treatment, and at least five patients have filed claims with the VA. More are expected.
It’s bad enough to give substandard medical care to people who sacrificed for their country. But the injury is compounded by the apparent reluctance of various agencies to face up to the episode and to ensure that similar problems don’t happen again.
The Nuclear Regulatory Commission, which oversees the medical use of radiation, has reached disturbing conclusions in a report on the program. It said the Philadelphia VA staff didn’t know when to report mistakes. And the cancer-treatment team didn’t even check radiation doses for more than a year because a computer wasn’t working.
The VA’s own review of the program contained errors, the NRC said. And the VA didn’t compile a complete list of the overdoses and underdoses of radiation until last month.
The NRC will hold a public meeting Dec. 17 to decide what, if any, action to take against the VA Medical Center. The possible penalties range from a reprimand to stiff fines. The Department of Veterans Affairs’ inspector general is conducting a separate investigation.
Veterans and the taxpaying public deserve a full accounting of how these mistakes in the program occurred, why it took so long for the problems to come to light, and who wasn’t doing his job.
The Department of Veterans Affairs also needs to explain how it intends to ensure better safeguards for its medical care going forward.

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