Tuesday, June 23, 2009

Brachytherapy for Prostate Cancer

Maybe you saw the reported botched prostate cancer therapy report in the news this weekend. Prostate cancer kills 25,000 men each year. Twenty per cent of the male population develops the cancer over their lifespan. While very common, only 3% of those who get it actually die from the disease.

Brachytherapy is a new type of therapy in which radioactive implants are placed directly in the tumor field of the diseased prostate gland. The radiation kills the nearby cancer cells. It is generally very safe with few side effects. Usually, the risk of anesthesia is the riskiest part of therapy.

Apparently, a doctor and surgical team in the Philadelphia VA hospital did not place the implants correctly and caused some severe problems. Over six years, 92 of 116 procedures were incorrectly performed as reported by Walt Bogdanich in THE NEW YORK TIMES (June 21).

The radioactive seeds are placed n the gland with the use of an ultrasound images that are put together to produce a three dimensional representation of the gland by a computer. The surgeon then places a needle into the gland and manually inserts the radioactive seed into place. Hundreds of seeds can be used. You want the majority to be placed within the gland.

The computer displays placement of the seeds. If the surgeon decides they are in the right position, then the procedure is considered successfully completed. However, the seeds can be placed outside the gland near other tissue like the bladder or rectum.

This can cause radiation damage to the local tissue. One of the patients in the article suffered radiation injury to the anal canal. If not placed in the gland, the cancer is not treated properly and the procedure needs to be repeated.

It appears that peer review and other safety procedures failed in the hospital to detect these failed procedures. The radiation dosing machine that measures the adequacy of the radiation therapy was broken. Even so, the treatments were still done. There also was inadequate peer review of the procedure. The program opened in 2002 and was ended after these results become known.

The most frightening thing in this whole episode is that it may not have even been discovered if an order for seeds had not gone awry. A clerical error led to the problem’s discovery.

Lower dose seeds were incorrectly ordered and used for implantation. The nuclear commission noticed this and asked the hospital to investigate. What they found was that the seeds had been improperly placed in several cases. They looked at more cases and found more problems: 45 in all.

The program was stopped. The nuclear commission concluded that many case had undertreated the prostate as seed had been placed in the wrong areas or some other non-prostate tissues had been overdosed by radiation. None of this was reported to proper officials. The cases mismanaged mounted.

A major system failure occurred here. The nuclear commission did not feel they were responsible to report this as they did not regulate medicine. Peer review by doctors of the surgeon and his team also failed. There is no excuse for this. What do you think?


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