A new charge of malpractice against VA hospital

Barry Lackro was exposed to the notoriously toxic defoliant Agent Orange in Vietnam in the early 1970s.

He wasn't surprised when he developed prostate cancer in 2004 at age 54, but he took heart that the malignancy was caught early and was highly curable with either surgery or radiation.

Today, almost five years later, he not only has terrible complications from his treatment, but also expects the cancer to kill him.

Lackro's complex case raises new questions about the quality of prostate-cancer care provided by the Philadelphia VA Medical Center and its contractor, the University of Pennsylvania Health System.

Lackro is one of the 92 veterans that the Philadelphia VA admits received too little radiation - or too much - from radioactive brachytherapy seed implants done between 2002 and 2008.

What makes Lackro's case unusual, if not unique, is that he opted for brachytherapy after Penn physicians tried and failed to remove his prostate. They aborted the operation because of a complication Lackro says he warned them about.

Now, the former Special Forces officer faces bleak treatment choices. His lawyer, Mitchell Paul, has filed a claim against the VA.

"I'm angry about what was done to me - and to all of us," Lackro, 59, of Philadelphia, said last week in Paul's Center City office. "When I was an officer, I was concerned about my whole group. I feel the same way now."

In brachytherapy, metal seeds the size of rice grains are injected into the prostate using special needles and ultrasound imaging of the pelvic organs. The seeds emit cell-killing radiation for about 10 months.

Introduced in the early 1990s, brachytherapy is now a popular option for patients with early, nonaggressive cancer that has not spread beyond the prostate.

For Lackro, the diagnosis added to an already-lengthy list of health problems, many related to his two tours of duty in Vietnam.

Not that he regrets that service. He proudly showed his green beret from that elite Army force, and a presidential certificate commissioning him a first lieutenant.

But those three years took a heavy physical toll. He shattered vertebrae in his back when a land-mine explosion threw him, like a rag doll, out of a jeep. He was shot in the thigh, which now forces him to walk with a cane. He still suffers from a psoriasis-like skin condition that soldiers knew as "jungle rot." And he has been treated for post-traumatic-stress syndrome.

Lackro, a marine biology major in college, worked as a teacher and a corporate manager for American Express after leaving the service. But by 2001, his deteriorating health qualified him for full disability benefits.

In summer 2004, a prostate-cancer screening led to a biopsy. His medical records show he was diagnosed with stage "T1c" prostate cancer - a tumor too small to be felt during a prostate exam.

Lackro says he was in favor of radiation, either externally or with brachytherapy, but was advised against it.

The patient "was initially interested in xrt [external radiation therapy] but he was considered to be a poor candidate b/c of his age and" skin disorder, a Penn medical resident wrote in August 2005.

Prostate-removal surgery is considered the gold standard for early malignancy in younger men - those under age 60 - because it offers the best chance for cure.

In his report, the resident wrote that with surgery "chance of cure [is] 90 percent." He listed the risks of impotence as 30-40 percent; of incontinence, 5-6 percent; of rectal damage, less than 1 percent.

Lackro's wife, Beverly, and daughter, Alicia, a medical student at Drexel University College of Medicine, also wanted him to go for surgery.

Lackro was concerned that surgery wasn't wise. In 1989 and 1993, he had plastic polymer mesh placed in his pelvic cavity to repair hernias - intestinal weak spots that bulge through the abdominal wall.

The medical literature contains numerous articles describing prostate removal in men like Lackro as "difficult or impossible" because the mesh induces thick scarring that can obscure and stick to pelvic organs and structures.

Lackro never checked that literature; he simply understood male pelvic anatomy.

"I knew I had two meshes and I said to the [VA] surgeons, you're not going to be able to get to the prostate gland," Lackro recalls. "They said, 'We'll deal with it.' "

In the two-inch pile of records Lackro obtained from the Philadelphia VA, his hernia operations are noted many times - but not mentioned as a possible complication for prostate removal.

A spokeswoman for Penn would not comment on the case. The VA would not accept an e-mailed authorization from Lackro's lawyer as permission to comment.

Lackro says he spent "61/2 hours on the table" on Oct. 25, 2004, before his surgery was abandoned.

Over the next two days, his records show, he received conflicting information when he asked about brachytherapy. A Penn radiation oncologist advised against it because Lackro's skin condition "may impart a higher risk of postoperative infection." A Penn dermatologist disagreed.

On Jan. 10, 2005, Lackro had 61 seeds implanted - not including one removed from his bladder and three seeds that came out in blood clots. His records do not specify the prescribed radiation dosage or his actual dosage.

By April, Lackro was complaining of blood in his urine and stools, constipation, rectal pain, and urinary urgency and frequency, his records show.

Eventually, these complaints were referred to as "radiation proctitis and cystitis" - radiation irritation to the rectum and bladder. But none of his VA health-care providers suggested these side effects might be due to substandard brachytherapy, Lackro said.

Lackro did not learn that the VA was reviewing all the brachytherapy cases until last August - when he read a story in The Inquirer that said the VA had sent a letter informing the affected veterans.

"I never got that letter," Lackro said.

After calling the VA and talking to a Penn radiation specialist, Lackro received a letter that said his prostate had received "adequate" radiation, but "some seeds" placed outside the prostate "contributed to a high dose to the rectum."

Lackro's PSA blood test, used to monitor for signs of cancer, fell into a safe range and stayed there for about 19 months after the seeds were implanted. Since then, it has steadily risen to an alarming level.

Lackro is now being treated at Fox Chase Cancer Center, where doctors reviewed his limited options: hormone treatment to slow but not cure the cancer, or massive, dangerous surgery to remove his prostate, his bladder, and, depending on the extent of the rectal damage, his colon. Surgery would require rerouting urine and feces to external collection bags.

"My mother died of colon cancer and was on a bag. I won't do that," Lackro said. "My dignity has been abridged enough. The cancer will take me before I do that."