"They ought not have to wait for a front-page newspaper article or a Senate committee hearing to do what they should have done on their own," said Sen. Arlen Specter (D., Pa.), one of the lawmakers who feels the VA has been slow to respond. "I think that it is regrettably necessary to keep pressure on them to follow up."
Newly obtained documents shed more light on the program, showing that the mistakes began with the earliest cases, starting in 2002, and that the hospital missed numerous opportunities to catch them.
In one 2003 case, for example, more than half the radioactive seeds landed in the patient's bladder instead of in the prostate. Yet no program-wide review ensued, and the brachytherapy treatments continued for five more years.
Gary Kao, the Penn radiation oncologist who directed the program, has been the public whipping boy for its flaws. He lost his VA position when the program was closed but was never officially sanctioned by the hospital. He's now on leave from Penn.
A whole team worked with Kao and shares responsibility for what happened, say investigators from the VA and other agencies.
So does the Nuclear Regulatory Commission, which oversees the medical use of radioactive materials. The NRC reviewed several of the worst Philadelphia cases, including the 2003 case, and failed to stop the procedures.
From February 2002 to June 2008, the month the implant program was closed, 98 of 114 veterans treated got incorrect doses of radiation.
Federal investigators have found that 63 were underdosed and that 35 got too much radiation to tissue near their prostates.
The mistakes led to internal investigations, congressional scrutiny, and probes by the NRC and the VA's inspector general.
