Regulators Discover "Rogue Cancer Unit" at Philadelphia V.A. Hospital

Brachytherapy is a new technique to treat Prostate Cancer that has been utilized since 2002 at the Philadelphia Veterans’ Hospital. In the procedure, small metal seeds are permanently injected into the prostate with needles. The seeds are so small that they are approximately the size of a grain of rice. Nevertheless, no matter how small these seeds may be, many veterans have experienced tremendous pain as a result of botched brachytherapy procedures performed at the Philadelphia V.A. Hospital. In fact, 92 out of 116 veterans that were treated over the past six years received incorrect dosages—significantly less than what was needed, while others received excessive amounts of the radiation treatment to nearby tissue and organs.

There might not have been so many botched procedures if the hospital had had some kind of peer review system, where colleagues inspect one another’s work; the hospital operated with nearly no such safeguards. The V.A.’s radiation safety program, The Nuclear Regulatory Commission, which regulates the use of nuclear materials, and the Joint Commission, a group that accredited the hospital, all failed to intervene either because their inspections were too limited or they did not probe deeper into problems they did identify. In fact, the chief operating doctor at the Philadelphia V.A. Hospital was allowed to sweep his mistakes under the rug more than once under the discretion of federal regulators, or failed to report his mistakes to them at all—mistakes that included implanting the seeds in the wrong organs and using broken equipment that is used to ensure a patient receives the proper radiation dosage.

Federal investigators are just now probing deeper into the issue, ironically because of a clerical error that mistakenly revealed the substandard implant procedures. In the spring of 2008, a radiation safety official accidently ordered lower strength seeds, which were ultimately implanted. After the error was discovered, the V.A.’s national radiation safety unit asked the hospital to investigate 10 to 20 more cases to see if the problem had occurred before. It had not, but they did discover the procedures where seeds were implanted in the wrong organ. The hospital suspended the brachytherapy program on June 11 of last year and the chief operating doctor, who had performed all but a handful of the botched procedures, was removed from the hospital. No veterans have reportedly died as a result of the procedure, but they have suffered needlessly because of the Philadelphia V.A. Hospital’s lack of oversight and concern for the proper care of our veterans.