More NY Times: SRS overdoses

[Gfunk6]

http://www.nytimes.com/2010/12/29/health/29radiation.html?hp

Scary stuff.

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[CNphair]

Somewhere, Brainlab and Varian PR reps aren't having a good day.

I do find this passage interesting:
"Earlier this year, CoxHealth announced that it had overradiated 76 patients, most of whom had brain cancer, during SRS treatments. The overdoses had continued for five years because the hospital did not realize that its radiation therapy equipment had been set up incorrectly.
The hospital’s medical physicist, who was apparently accustomed to calibrating larger radiation beams, did not realize that smaller beams needed to be handled differently, radiation experts say."

Speaks to the importance of maintaining a solid QA program and not having technology go beyond the reach of your staff training - both MD and physicist. The new toys are exceedingly attractive from both a financial and management standpoint, but they can also be dangerous in the wrong hands.

 

[medgator]

Speaks to the importance of maintaining a solid QA program and not having technology go beyond the reach of your staff training - both MD and physicist. The new toys are exceedingly attractive from both a financial and management standpoint, but they can also be dangerous in the wrong hands.

I've gotta say, if I am giving 85 Gy to the trigeminal nerve, nothing makes me feel safer doing that than a Gamma Knife. It's simple and has been time-tested. TN is the one SRS indication that scares me when it is applied across platforms, simply because of the dose involved and the proximity of the brainstem.

 

[CNphair]

I've gotta say, if I am giving 85 Gy to the trigeminal nerve, nothing makes me feel safer doing that than a Gamma Knife. It's simple and has been time-tested. TN is the one SRS indication that scares me when it is applied across platforms, simply because of the dose involved and the proximity of the brainstem.

Treating TN with SRS requires a healthy respect...agree that gamma knife is a much more straight forward procedure, however, I think it can be safely and accurately treated with other modalities. But when you get into frameless techniques with retrofitted linacs in community centers with part time physicists, etc etc...I would just be scared.

A fear that will hopefully keep me off the front page of the NY Times.

 

[medgator]

Treating TN with SRS requires a healthy respect...agree that gamma knife is a much more straight forward procedure, however, I think it can be safely and accurately treated with other modalities.

Oh yeah I'm sure it can. Going frameless for a TN makes me nervous nonetheless.

But when you get into frameless techniques with retrofitted linacs in community centers with part time physicists, etc etc...I would just be scared.

A fear that will hopefully keep me off the front page of the NY Times.

Exactly

 

[deleted4401]

Scary.

Evanston is a pretty damn good community cancer center.

So are they saying that the jaws around the cone were too big and there was leakage through the periphery? I don't get it exactly.

-S

 

[medgator]

Scary.

Evanston is a pretty damn good community cancer center.

So are they saying that the jaws around the cone were too big and there was leakage through the periphery? I don't get it exactly.

-S

That's exactly what they are saying (as far as I can tell). No one caught it either, and it's hard to tell because a plate that holds the cone obstructs the light field on the patient's skin, so as a last-minute check, that wouldn't have worked.

From the article:

Linear accelerators can be adapted to perform stereotactic radiosurgery in two ways: with small computer-controlled metal leaves that shape the beam, or with a cone attached to the machine's opening through which radiation is delivered. That opening is made smaller or larger by moving four heavy metal "jaws" that shape the beam into a square. When a cone attachment is used, the square beam must fit entirely within the circumference of the cone. If the square is slightly larger than the cone, radiation will leak out through the four corners of the jaws and irradiate healthy tissue. In the Evanston accidents, records show, the beam was four times too large.

Operators could not see this incorrect setting directly because a metal tray on which the cone is mounted hides the jaws, though the settings should have been displayed on a computer screen, according to people who have worked with this device. The mount also blocks a light field that could have shown where the radiation was to hit the patient.

But while the mount blocks light, it does not block radiation, which in the case of Ms. Faber and other Evanston patients went into healthy brain cells.

 

[Gfunk6]

ASTRO official response:

ASTRO committed to patient safety, eliminating medical errors

The American Society for Radiation Oncology (ASTRO) is gravely concerned about the treatment errors reported in the December 28, 2010, The New York Times article "A Pinpoint Beams Strays Invisibly, Harming Instead of Healing." We grieve for the individuals and families that have been affected by these errors, and we are committed to ensuring the highest standards of safety for patients.*

Radiation therapy has been, for nearly a century, one of the cornerstones of cancer treatment. In 2010, more than 1.1 million cancer patients received it as part of their treatment. This highly effective therapy helps patients to maintain their quality of life while conquering their cancer. Radiation oncologists, together with treatment teams made up of physicists, nurses, radiation therapists and dosimetrists, have many safety measures and protections built into our processes of care. All available evidence indicates that errors like the ones described in this article are extremely rare. However, as with flying a plane, even a single error is one too many and our specialty is working to eliminate them.

In 2004, ASTRO recognized that the exciting expansion of new medical technology carried risks unless there was perfect communication between software and hardware, regardless of the manufacturer. We established a program known by the acronym IHE-RO (Integrating the Healthcare Enterprise-Radiation Oncology) and, over the past six years, have contributed significant resources to ensure that medical technologies from different manufacturers can seamlessly transfer information. The article rightly notes that the lack of connectivity among systems is still a problem. We are grateful to those manufacturers who have participated in IHE-RO but now call on the others to join and all to quickly implement the solutions developed as well as other essential safety features. We now strongly encourage all radiation oncologists and their hospitals to consider only IHE-RO compliant technologies when selecting new radiation therapy equipment. Regulation may be required to ensure that this happ
ens.

In January 2010, ASTRO launched its Target Safely campaign, a comprehensive plan to help to ratchet patient safety up even further. As the article mentioned, ASTRO has proposed federal legislation to develop a national medical error reporting system and a patient safety database for radiation oncology. Error and near-miss reporting will not only detect sporadic problems and find patterns but will allow for the rapid and wide dissemination of alerts when problems occur in the manner of the recent "Toyota recalls." ASTRO has proposed strong and credible radiation oncology practice accreditation through its recently intensified accreditation program. We also have proposed immediate passage of legislation to require licensing standards for personnel performing radiation treatments. This article again highlights why such legislation is needed, and we want to work with the new Congress and federal officials to enact these necessary and urgent reforms.

Every individual on the radiation oncology team has to be immersed in the culture of quality assurance and quality improvement. To this end, we have fortified our educational program for radiation oncologists wishing to maintain their physician certification with additional content focused on just these issues. We are producing a series of consensus-based white papers on safety and quality, with a specific focus on newer technologies such as stereotactic radiosurgery. ASTRO will update its recommendations in early 2011 to address staffing and oversight. While we would like Congress to act we cannot wait and will set our own high bar. Every facility must have the physics support and manpower to check, double-check and then check again before any treatment is delivered.

What is a patient to do? How can they know whether their radiation oncology facility is operating at the safest level? ASTRO has worked with patient supports groups, cancer survivors and other medical organizations to create a list of questions patients should ask their physicians and cancer centers when considering radiation therapy as a treatment for their disease. These are designed to help patients better understand the safety checks and balances that are put into place to guard against errors. We have made these questions available for download on our patient website rtanswers.org and to view as videos posted at www.youtube.com/user/ASTROTargetingCancer. It is vital that patients are actively involved in their treatments and are confident that radiation therapy is safe and effective. No passenger would step on a plane if they were not confident that the entire airline industry put safety first. The radiation oncology profession must prove it is doing the same.

ASTRO wants patients to have peace of mind when it comes to the safety, quality and efficacy of radiation therapy; 99.99 percent is good but not good enough. We are deeply committed to stronger error reporting, more training, enhanced accreditation, better use of health information technology, patient-centered educational tools and federal advocacy to help protect patients. Cancer patients have enough to worry about; they should not have to worry about this.

Anthony L. Zietman, M.D.
Chairman, American Society for Radiation Oncology, the world's largest radiation oncology society with 10,000 members, and a radiation oncologist at Massachusetts General Hospital in Boston

 

[Charles_Carmichael]

ASTRO official response:

Well-written response, IMO.

 

[medgator]

Well-written response, IMO.

Yup. Unfortunately, it's the second response from ASTRO to the NYT this year

Back in January: http://cs.astro.org/blogs/astronews...er-to-the-new-york-times-january-25-2010.aspx

 

[arthurdent]

Well-written response, IMO.

I personally might not have invoked Toyota...

 

[Charles_Carmichael]

Sorry for the late response.

Yup. Unfortunately, it's the second response from ASTRO to the NYT this year

Back in January: http://cs.astro.org/blogs/astronews...er-to-the-new-york-times-january-25-2010.aspx

Yea, I definitely remember that article too. I posted several times in the comments also in defense of radonc.

I personally might not have invoked Toyota...

I don't know. I didn't think that they mentioned it in a negative manner. I thought that they were pointing out how Toyota was able to get the word out really quickly for recalls. When I read that sentence, I thought of it in that positive sense rather than negatively. Who knows? Maybe I'm wrong.