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V.A. Hospital botches prostate cancer therapy for 92 of 116 veterans

The New York Times' Sunday edition disclosed details of an investigation into cancer therapy provided at a Philadelphia Veterans Administration Hospital.  The VA has recently acknowledged that the care was sub-standard and described the events that unfolded between 2002 and 2008, identifying 92 cases of malpractice in 116 treatments over a span of six years.

The problem began when the VA hired a cancer-research physician specialist from the University of Pennylvania Medical School to provide brachytherapy to veterans in Philadelphia.  Brachytherapy is the insertion of rice grain-sized radioactive pellets into the prostate to radiate tumor cells and is sometimes an appropriate substitute for surgery or external radiation.

Unfortunately, the primary consultant hired by the Hospial was Dr. Gary Kao.  Kao, has a medical degree from Johns Hopkins, a Ph.D. from Penn, is board-certified in radiation oncology and won a contract from NASA to study radiation in space.  He was inexperienced in providing brachytherapy, however, and the VA Hospital did not institute any form of peer review for the new unit.

According to the recently completed investigation, Kao was responsible for most of the 92 substandard treatment cases where radioactive pellets were  improperly inserted so that they either did not treat the prostate, over-radiated other organs, or both.  The New York Times suggested that on two occasions Kau re-wrote medical records with the effect of obscuring major mistakes in placing radiation seeds.  (In one case, he placed 40 seeds in the patient's healthy bladder, rather than the prostate, and botched a second insertion, as well, causing intended radiation to the rectum.  In the other case of "chart revision,"  he put half of the inserted seeds into the wrong organ.)

The VA ultimately closed the Philadelphia prostate unit in mid-2008, and has also suspended similar treatments in hospitals in Jackson, Mississippi and Cincinnati.  The problems in Philadelphia were only discovered as a result of a clerical error in ordering implant seeds in the spring of 2008.  When seeds with the wrong dosage were ordered, a follow-up review was instituted to see if improper-dosage seeds had been used in the past.  This investigation inadvertently uncovered the systemic problem of improper placement that had commenced in 2002.

The hospital suspended brachytherapy on June 11 of 2008, and two days later the Joint Commission on Accreditation of Hospitals (the JCAH or "Joint Commission") continued accreditation of the hospital with the conclusion that "This organization is in full compliance with applicable standards."  For some time, it has been apparent that the JCAH, a non-governmental, voluntary regulatory organization funded by the hospitals, is inadequate to the role it has assumed in U.S. medicine.  In prior blog entries and in various books and articles, writers have documented the futile and frequently superficial regulatory practice of the JCAH:  one author pointed out that the only (two?) hospitals ever to lose their accreditation by the JCAH were forced to close their doors by outside events before de-certification became effective.

The current study noted that 57 implant patients did not receive adequate radiation to the prostate, 35 patients received overdoses to other organs or tissue and "16 patients received seed implants even though computer interface problems prevented medical personnel from determining whether those treatments had been successful."  Penn's medical school and health system acknowledged that Kao has now voluntarily relinquished his clinical medical privileges at Penn, and seven of the patients who recieved botched care in Philadelphia were flown to a VA hospital in Seattle for follow-up. 

Reverend Ricardo Flippin, the only patient/victim identified by name in the account of this story, is a 21-year Air Force veteran/retiree who suffered radiation damage to his rectum at Philadelphia and subsequently underwent follow-up care at Ohio State.  The VA system had been unable to identify the source of his pain and incontinence  for years and recommended a treatment plan that consisted only of heavy-duty pain meds.   Flippin was forced to give up his first job in the ministry because of his pain and lack of bowel control, and was justifiably disappointed in the VA treatment he received.  After being notified of the Philadelphia mess (by a notice that misspelled his first name), Flippin told an interviewer that "Any veteran should expect more than what we're getting."  We agree.  All too often the VA medical system is a poor sub-standard alternative for men and women who have earned better.

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