More than a year after the Philadelphia VA Medical Center said it had given substandard care to nearly 100 veterans with prostate cancer, the list of sanctions is sparse:

One physician accepted a three-day suspension. A radiation safety official got a letter of reprimand. And the University of Pennsylvania doctor who performed most of the poor procedures lost his job when the Philadelphia VA closed the program.

Several lawmakers who have investigated the cases said that the Department of Veterans Affairs' actions were both anemic and late, and that the agency had acted only after prominent newspaper articles appeared in the summer, detailing radiation overdoses and underdoses.

"They ought not have to wait for a front-page newspaper article or a Senate committee hearing to do what they should have done on their own," said Sen. Arlen Specter (D., Pa.), one of the lawmakers who feels the VA has been slow to respond. "I think that it is regrettably necessary to keep pressure on them to follow up."

Newly obtained documents shed more light on the program, showing that the mistakes began with the earliest cases, starting in 2002, and that the hospital missed numerous opportunities to catch them.

In one 2003 case, for example, more than half the radioactive seeds landed in the patient's bladder instead of in the prostate. Yet no program-wide review ensued, and the brachytherapy treatments continued for five more years.

Gary Kao, the Penn radiation oncologist who directed the program, has been the public whipping boy for its flaws. He lost his VA position when the program was closed but was never officially sanctioned by the hospital. He's now on leave from Penn.

A whole team worked with Kao and shares responsibility for what happened, say investigators from the VA and other agencies.

So does the Nuclear Regulatory Commission, which oversees the medical use of radioactive materials. The NRC reviewed several of the worst Philadelphia cases, including the 2003 case, and failed to stop the procedures.

From February 2002 to June 2008, the month the implant program was closed, 98 of 114 veterans treated got incorrect doses of radiation.

Federal investigators have found that 63 were underdosed and that 35 got too much radiation to tissue near their prostates.

The mistakes led to internal investigations, congressional scrutiny, and probes by the NRC and the VA's inspector general.

The NRC is expected to issue a report on the hospital's violations this week, followed by enforcement actions against the Philadelphia VA ranging from a violation notice to a fine of thousands of dollars.

At least five veterans have filed claims seeking compensation from the VA. The number is expected to rise since the VA has advised all the veterans of their rights to pursue legal action.

Gerald Cross, acting undersecretary for health at the Veterans Health Administration, and other officials ascribed delays to giving employees due process.

"Perhaps there were some missed opportunities" early on, Cross said, but he added that the agency had responded quickly when it identified a problem.

"We found it. We reported it. We took action" to stop the program, he said last month on his third visit to the medical center this year.

Cross said the VA was carefully monitoring the patients to ensure everything possible was being done for them.

Ten veterans have had a recurrence of their prostate cancer, according to the VA. And nine others show signs of a possible return.

Much of that may have been avoided if someone at the Philadelphia VA had been monitoring the quality of the implants performed by its team, led by Penn's Kao.