NY Times article details radiation therapy errors

By Cynthia E. Keen, AuntMinnie.com staff writer

January 26, 2010 -- While cancer patients are undergoing radiation therapy intended to cure them, serious mistakes may be made, all attributable to failure by medical staff to follow detailed, established quality assurance protocols, according to an article published January 24 in the New York Times.

The New York Times investigated radiation therapy adverse events that were reported in the state of New York from 2001 through 2008. The article presented the follow conclusions:

  • Inappropriately delivered radiation therapy treatments can kill and maim patients.
  • There is no way for a patient to obtain the adverse event record of a cancer treatment center offering radiation therapy in the state of New York, because this information has been kept confidential since the 1980s by state health agencies to encourage hospitals to report adverse events.
  • The number of adverse events involving radiation therapy that occur in the U.S. is unknown, because some states do not require event reporting, no single government agency oversees medical radiation, and no central clearinghouse collects this data.

The article, written by investigative reporter Walt Bogdanich, stated that the New York Times selected the state of New York to investigate accidents because it is a leader in monitoring radiation therapy and collecting data about errors. Bogdanich identified 621 adverse events after reviewing thousands of pages of public and private records and interviewing medical physicists, researchers, and government regulators.

The adverse events included:

  • 133 incidents of errors associated with devices used to shape or modulate radiation beams, either from being left out, wrongly positioned, or otherwise misused.
  • 284 incidents of radiation doses missing all or part of their intended target, or irradiating the wrong body part.
  • The mix-up of radiation treatments for 50 patients who received the wrong radiation therapy as a result. This included one brain cancer patient who received a radiation treatment for breast cancer.

The article said that one reason for the problems is that clinical staff relies too heavily on computer systems of radiation therapy equipment. The New York Times also said that errors can occur when medical physicists do not double-check the output of computer software, and when radiation oncology technologists fail to monitor the equipment's computer consoles during treatment sessions.

Many other errors are the result of failure to comply with established quality assurance protocols, examples of which Bogdanich reported in detail.

Dr. Tim R. Williams, chairman of the American Society for Radiation Oncology (ASTRO) of Fairfax, VA, responded to the article with a letter to the editor of the New York Times stating that the 621 cited radiation errors are "exceptionally misleading" and represent an error rate of 0.0046% based on an estimated 13.6 million radiation therapy treatments (with each fraction of radiation counted as a separate treatment) performed in New York during the eight-year period in question.

By Cynthia E. Keen
AuntMinnie.com staff writer
January 26, 2010

Adverse events common with chemoradiation for head and neck cancers, December 22, 2009

NY Times story claims treatment errors at VA brachytherapy unit, June 23, 2009

Options abound for radiation therapy QC, August 19, 2008

QA tool cuts errors in radiation oncology department, August 6, 2008

AHRQ sets 2008 target for error reporting system, August 24, 2007

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