VA clears most facilities in prostate cancer treatment probe

Veterans Health Administration doctors investigating radiation underdosing of prostate cancer patients said they have found no problems at nine of 13 medical facilities that perform the treatment known as brachytherapy.

Brachytherapy is a complex procedure that involves implanting radioactive seeds into the prostate. In May, a physicist at the Philadelphia VA Medical Center discovered that a patient had received a lower-than-prescribed dose of radiation, prompting a probe that uncovered more than 90 additional cases of incorrect dosages at the facility since the cancer treatment program's inception there in 2002.

The problems in Philadelphia prompted VA to investigate its 12 other medical facilities that perform brachytherapy. In reviewing the 10 most recent procedures performed at each of the facilities, VA found several additional potential cases of underdosing at centers in Washington, D.C.; Jackson, Miss.; and Cincinnati, Ohio.

So far, VA has found no evidence that any patients have suffered adverse outcomes as a result of the underdosing, said Dr. Madhulika Agarwal, VA's chief patient care services officer.

"We have some limited data that show the [cancer] recurrence rate is no different from the national average," said Dr. Charles Anderson, a radiologist and chief consultant of diagnostic services. "Understand that prostate cancer is a very slow-growing tumor and you may not know for 10 or more years. Most people with prostate cancer die of something else."

VA has convened a multidisciplinary team of medical specialists to examine the findings at the three additional medical centers with cases of potential underdosing. The team will determine if the investigation should be expanded beyond the initial 10 cases examined at those hospitals, Anderson said.

According to reports VA filed with the Nuclear Regulatory Commission, which licenses VA's radiation programs and has initiated its own review of operations at the medical centers, nine cases of underdosing were identified at Jackson, six at Cincinnati, and three at Washington.

"There's no question that those numbers [reported to NRC] are going to change," Anderson said. "In some cases they may go down and in other cases they may go up. It's going to depend on how far we look back at previous patients."

Agarwal said one reason the numbers likely will change is that some initial findings were based on CAT scans taken very soon after the procedure was conducted. Because the radioactive seeds are metal and show up on the scans, specialists can determine the dosage based on the scans and seed placement. But post-procedure swelling can obscure the results and sometimes incorrectly indicate underdosing. In a couple of cases subsequent CAT scans have shown the dosing to be correct, she said.

A significant number of the underdosing cases discovered in Philadelphia resulted from radioactive seeds being inadvertently placed in other organs, said Anderson. Two of the 57 patients found to have received lower-than-prescribed doses have since died of unrelated causes, according to VA.

An additional 36 patients in Philadelphia were discovered to have seeds implanted in organs other than the prostate. "In terms of the number of seeds outside the prostate, Philadelphia was the most serious," Anderson said. Because of the ongoing investigation, Anderson said he could not disclose whether those procedures were tied to a particular physician or if there were other potential causes.

In some cases, contract doctors were in charge of the implants, but all were experienced physicians who routinely perform brachytherapy, Agarwal said. "We do not have trainees in our radiation oncology programs in the VA," she said.

The problems encountered in the three additional hospitals were of a lower magnitude than those in Philadelphia, Anderson said. "As a result of this, VA is going to have some very clearly delineated seed-placement metrics that we're going to follow," he said. "It will be a national program. We've looked to the private sector to see how they handle it and nobody seems to have a good process, so we're having to invent some of it ourselves."

VA has scheduled a conference in early January to bring all of the agency's radiation oncologists together to discuss the findings in the ongoing probe and develop more stringent guidelines for performing brachytherapy.