The Radiation Boom - Radiation Offers New Cures, and Ways to Do Harm - Series - NYTimes.comAs Scott Jerome-Parks lay dying, he clung to this wish: that his fatal radiation overdose — which left him deaf, struggling to see, unable to swallow, burned, with his teeth falling out, with
ulcers in his mouth and throat, nauseated, in severe pain and finally unable to breathe — be studied and talked about publicly so that others might not have to live his nightmare.
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A New York City hospital treating him for tongue
cancer had failed to detect a computer error that directed a linear accelerator to blast his brain stem and neck with errant beams of radiation. Not once, but on three consecutive days.
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But on the day of the warning, at the
State University of New York Downstate Medical Center in Brooklyn, a 32-year-old
breast cancer patient named Alexandra Jn-Charles absorbed the first of 27 days of radiation overdoses, each three times the prescribed amount. A linear accelerator with a missing filter would burn a hole in her chest, leaving a gaping wound so painful that this mother of two young children considered
suicide.
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Yet while Mr. Jerome-Parks had hoped that others might learn from his misfortune, the details of his case — and Ms. Jn-Charles’s — have until now been shielded from public view by the government, doctors and the hospital.
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But patients often know little about the harm that can result when safety rules are violated and ever more powerful and technologically complex machines go awry. To better understand those risks, The New York Times examined thousands of pages of public and private records and interviewed physicians, medical physicists, researchers and government regulators.
The Times found that while this new technology allows doctors to more accurately attack tumors and reduce certain mistakes, its complexity has created new avenues for error — through software flaws, faulty programming, poor safety procedures or inadequate staffing and training. When those errors occur, they can be crippling.
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Regulators and researchers can only guess how often radiotherapy accidents occur. With no single agency overseeing medical radiation, there is no central clearinghouse of cases. Accidents are chronically underreported, records show, and some states do not require that they be reported at all.
In June, The Times reported that a Philadelphia hospital gave the wrong radiation dose to more than 90 patients with prostate cancer — and then kept quiet about it. In 2005, a Florida hospital disclosed that 77 brain cancer patients had received 50 percent more radiation than prescribed because one of the most powerful — and supposedly precise — linear accelerators had been programmed incorrectly for nearly a year.
Dr. John J. Feldmeier, a radiation oncologist at the University of Toledo and a leading authority on the treatment of radiation injuries, estimates that 1 in 20 patients will suffer injuries.
Most are normal complications from radiation, not mistakes, Dr. Feldmeier said. But in some cases the line between the two is uncertain and a source of continuing debate.
“My suspicion is that maybe half of the accidents we don’t know about,” said Dr. Fred A. Mettler Jr., who has investigated radiation accidents around the world and has written books on medical radiation.
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Even though many accident details are confidential under state law, the records described 621 mistakes from 2001 to 2008. While most were minor, causing no immediate injury, they nonetheless illuminate underlying problems.
The Times found that on 133 occasions, devices used to shape or modulate radiation beams — contributing factors in the injuries to Mr. Jerome-Parks and Ms. Jn-Charles — were left out, wrongly positioned or otherwise misused.
On 284 occasions, radiation missed all or part of its intended target or treated the wrong body part entirely. In one case, radioactive seeds intended for a man’s cancerous prostate were instead implanted in the base of his penis. Another patient with stomach cancer was treated for prostate cancer. Fifty patients received radiation intended for someone else, including one brain cancer patient who received radiation intended for breast cancer.
New York health officials became so alarmed about mistakes and the underreporting of accidents that they issued a special alert in December 2004, asking hospitals to be more vigilant.
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Ms. Jn-Charles had been harmed by a baffling series of missteps, records show.
One therapist mistakenly programmed the computer for “wedge out” rather than “wedge in,” as the plan required. Another therapist failed to catch the error. And the physics staff repeatedly failed to notice it during their weekly checks of treatment records.
Even worse, therapists failed to notice that during treatment, their computer screen clearly showed that the wedge was missing. Only weeks earlier, state health officials had sent a notice, reminding hospitals that therapists “must closely monitor” their computer screens.
“The fact that therapists failed to notice ‘wedge OUT’ on 27 occasions is disturbing,” Dr. Tobias Lickerman, director of the city’s Radioactive Materials Division, wrote in a report on the incident. The hospital declined to discuss the case.
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Accidents and Accountability
Patients who wish to vet New York radiotherapy centers before selecting one cannot do so, because the state will not disclose where or how often medical mistakes occur.
To encourage hospitals to report medical mistakes, the State Legislature — with the support of the hospital industry — agreed in the 1980s to shield the identity of institutions making those mistakes. The law is so strict that even federal officials who regulate certain forms of radiotherapy cannot, under normal circumstances, have access to those names.
Even with this special protection, the strongest in the country, many radiation accidents go unreported in New York City and around the state. After The Times began asking about radiation accidents, the city’s Department of Health and Mental Hygiene reminded hospitals in July of their reporting obligation under the law. Studies of radiotherapy accidents, the city pointed out, “appear to be several orders of magnitude higher than what is being reported in New York City, indicating serious underreporting of these events.” ...
