I have taken a quick listen to the Senate Veterans’ Affairs Committee field hearing in Philadelphia on Monday (you can find the mp3 files here, along with witness statements). Nothing came out that was not already in the NRC report. However, Sen. Specter indicated that a hearing of the full committee in Washington will be forthcoming. That said, here are a few of my thoughts.
As expected, Dr. Kao tried to place blame on the lack of training and oversight by the VA radiation safety committee. Rep. Adler did a great job of keeping the focus on Dr. Kao. At one point, he expressed disbelief that Dr. Kao was still licensed to practice medicine. Dr. Kao (aided by Rep. Fattah) gave the impression that the types of errors committed at the Philadelphia VA are common in prostate brachytherapy but go mostly unreported. This is misleading. While it is true that one or two seeds often end up in organs beside the prostate, placing half of the seeds in the bladder is in no way a common event. He is probably correct, unfortunately, that other centers perform substandard implants, but if this magnitude of error was widespread, the outcomes from prostate brachytherapy nationwide would be horrible. Instead, brachytherapy has about the same success rate as external beam radiation or surgery. Fortunately, Steven Reynolds of the NRC did a good job of refuting this argument.
Despite my fears about this turning into a referendum on national health care, there were few comments in that direction. Sen. Specter asked a question relating to the need for a standards enforcement scheme in relation to health care reform. Rep. Fattah defended Dr. Kao and the Philadelphia VA in what seemed like an attempt to defend against the argument that this failing was indicative of government run health care. All in all, though, the direction of the hearing was productive. I still have my fears about the upcoming hearing in Washington, though.
At least one comment seemed to indicate that the Philadelphia VA was accredited by the ACR while these errors were occurring. A visit to the ACR accredited facilities web site shows the hospital having their accreditation under review. If it is true that the hospital was accredited, that basically blows my entire argument that ACR accreditation is the answer out of the water. It seems odd that the ACR would miss something as easy to find as a failure to perform post-implant dosimetry, unless they visited during the period after the CT transfer problems were worked out.
There were two misconceptions that I hope will be worked out before the next hearing. The first is the definition of a medical event. A medical event is very clearly defined, but there were a few questions asking if one seed placed in an organ other than the prostate is a medical event. What constitutes a medical event is the amount of dose given to the prostate and other organs. A single seed in the rectum will probably not give enough dose to rise to the level of a medical event. This misconception allowed Dr. Kao to make the argument that medical events are commonplace, but go unreported.
The second misconception is, as I wrote above, the idea that because prostate brachytherapy is “evolving”, that placing 40 seeds in the wrong organ is any kind of a common or expected event. If it is true that Dr. Kao refused to use to fluoroscopy during his procedures, that is a serious break with the standard of care in these procedures. The failure to perform post implant dosimetry is also contrary to standard practice. A report of the American Association of Medical Physicists (Task Group 64) states, “A quantitative dose analysis must be carried out for each patient postimplantation” (emphasis theirs). This is not a program that is being singled out unfairly. Their clinical practice was outside the norm.
Finally, the testimony of Rev. Ricardo C. Flippin was incredibly powerful and a reminder that is not some bureaucratic turf war. There are real lives at stake here.
