Philadelphia V.A. Hospital Botched 92 Treatments: Prostate Cancer Patients Receive Too Little or Too Much Radiation

According to an article in New York TImes Health by Walt Bogdanich on June 20, 2009, out of 116 prostate cancer patients receiving treatments, 92 of them were done wrong.

Dr. Gary D. Kao has a medical degree from Johns Hopkins and a PhD. from Penn. This year he worked on a team from Penn and they won a contract from NASA in the study of radiation in space. He was board certified in radiation oncology and had some experience in brachytherapy. Dr. Kao is under investigation as being the one who botched many of these treatments at the V.A. Medical Center in Philadelphia.

Brachytherapy Radioactive Seeds

Prostate cancer involves the implant of 40 to 130 radioactive seeds to attack the disease. These radioactive seeds are metal, about the size of a grain of rice. They emit low-energy radiation that is primarily absorbed in the treatment area around the seed. They inject these seeds with a needle into the prostate. When Dr Kao implanted 40 seeds into one patient, he placed them in the patient’s healthy bladder, not the prostate. The mistake was investigated, and they allowed Dr Kao to make his mistake disappear. He rewrote his surgical plan, omitting any mistake. This same patient had to undergo another implant, but this time, instead of putting the seeds in the prostate, Dr. Kao shot them into the patient's rectum. No one reported this mistake or the many others that followed.

The brachytherapy program began in 2002. Its purpose was to treat prostate cancer without having to resort to major surgery. This cancer unit not only allowed Dr. Kao to do the implants, without outside scrutiny, there was no peer review. Equipment that measured whether or not patients received the proper radioactive dose had been broken for a year. The reports show that the radiation safety committee at the Veterans Affairs hospital knew that the equipment was broken, but did nothing about it.

The doctor performing most of these implants did not use the real-time x-rays that showed the placement of the seeds. He refused flouroscopy saying he did not need it.

Reverend Ricardo Flipin’s Ordeal

In 2005, Reverend Ricardo Flipin discovered he had prostate cancer. He had choices of external beam radiation, surgery or brachytherapy. He chose the brachytherapy because Dr. Richard Whittington, chief of radiation oncology at Philadelplhia V.A., told him that it was relatively safe and that he had done over 600 seed implants before. Dr. Whittington did not do the implant. Dr. Kao did the implant.

Reverend Ricardo Flipin was given the wrong amount of radioactive seeds in the wrong organ,. He suffers from other health problems that this mistake caused him. After the procedure, Reverend Flipin couldn't walk or stand without being in severe rectal pain. He was in bed for 6 months causing him to lose his job at the church. Reverend Ricardo Flipin is a 21-year vet and he knew nothing about the radiation mistake until he went to an Ohio hospital in 2006 to get treatments

It was not until 2008 that the V.A. contacted Reverend Flipin. They addressed their letter to him with the wrong name, then informed him that he had received a flawed implant.

The nuclear committee had no reports about the substandard implants. These medical errors went without investigation for months and even years, not even the patients were aware of wrongful cancer treatments. The first year these implants began, nine were termed substandard and two of them happened on the same day. In 2003, the nuclear commission got their first solid clue that these procedures were not done right. Dr. Kao shot most of the 40 seeds into the patient' bladder. The urologist had to thread a small tube through the patients penis to retreive the seeds. The chief regulator, after learning of Dr Kao's mistake decided that because he revised his report, the mistake did not exist. They simply had the patient come back for another surgery

Investigations Begin

It was not until the spring of 2008 that a radiation safety officials at the V.A. ordered seeds of a lower strength and they were implanted in patients. This was what prompted the investigation. The error was caught this time and the V.A.‘s national radiation safety unit asked the hospital to reexamine some cases to see if this had occurred before.

While the federal investigation continues, the Philadelphia prostate unit was shut down in 2008 and has not reopened. The brachytherapy implants at hospitals in Jackson, Missouri and Cincinnati have also been suspended.

Dr Ronald E. Goans is a nuclear commission consultant. He reviewed about a fourth of the implants that were wrong. His verdict is that it was erratic seed placement that caused many cases to have elevated doses to the perinium, bladder or rectum.

On June 11, 2008, the brachytherapy unit was suspended and 45 cases of substandard implants were found. The Joint Commission reported that they were in full compliance with the standards, so the N.R.C. came to investigate. They discovered that 57 implants delivered too little radiation to the prostate. Either the seeds were placed in some other organ other than the prostate or they weren’t distributed properly within the prostate. They found 35 cases to be an overdose of radiation to other parts of the body and an undetermined number of patients were under-dosed in the prostate and over-dosed in another part of their body.

To date, Medical Center spokesman Dale Wardan says that the center is giving follow up care to all the veterans who received defective treatment.

Jul 30, 2009 9:32 AM

Guest :

The VA Hospital, a disappointment. They jerk soldiers around with paper work, skidding away from actual treatment, making soldiers go to one office for the first visit that does very little, and then makes them go to another facility miles away to see another doctor. Some so called primaary doctors are nurse practicioners. Then there is not ample parking, so when the soldier has to spend time looking to park he is late for his appointment, and then after him waiting weeks for this appointment, they tell him "you're later, we can't see you today. That sends him/her back to the beginning of having to set up another appointment, over again, making them wait for weeks or months, if they can't through. I called the VA # in Philadelphia one time for almost a year. The phone message was on a loop and kept sending me back to the same beginning message. I finally called the White House. In minutes I got the appointment. It was weeks to wait for the appointment. It was in Willow grove PA. Then the soldier went there to see a nurse practicioner, filled out paper work. He was supposed to get a blood test but the incompetent person working there let him sit for 45 minutes and then said, " Oh you're finished, you can go home. He left and then they called and said, " he was supposed to have a blood test. I said , "then why didn't you do it? What is the matter with the lot of you?" Finally weeks later he saw a doctor. In spite of his nose injury in the military that is blocking his air intake, they looked at him and said there's nothing wrong with your nose that we can see, you must have allergies. They then told him he should go to another hospital and get some allergy tests. Are they kidding? This soldier broke his nose in the war and he has a terrible time breathing. He feels sick because it's a struggle to get enough air into his nose constantly. After all of that waiting for appointments, the so called treatment turned out to be a lot of nonsense. This soldier thinks The VA had no intention of ever taking care of him. He applied for PTSD disability, and was turned down, because they wanted to know what happened in the war, with times and dates. He was made to sign papers by the military stating that he would never be permitted to talk about anything from the war. I think It's a disgrace the way the VA hospitals treat soldiers. The Gov. should issue every soldier a med card and let them get there own Med treatment. They'd be better off!