NRC acts against two in Philadelphia VA case

In what the Nuclear Regulatory Commission called its final - and extremely unusual - action involving six years of mistakes in prostate cancer procedures at the Philadelphia VA Medical Center, the agency said Wednesday that it had barred the primary physician from NRC-licensed activities.

Milder but still uncommon action was taken against a medical physicist involved in most of the cases.

Between 2002 and 2008, the NRC said, veterans underwent 116 brachytherapy procedures, in which radioactive seeds were implanted to kill tumor cells, at the Philadelphia VA. Incorrect doses were given in 97 of them.

"To have so many medical events occur, so many treatments going wrong, such a large number over such an extended period of time, delivered by the same doctor and the same medical physicist," said NRC spokeswoman Viktoria Mitlyng, "has never happened before."

Dozens of veterans have filed claims alleging harm from under- or overdosing, and the NRC last year fined the local facility $227,500 and the U.S. Department of Veterans Affairs another $39,000.

In the latest action, the NRC on Tuesday barred University of Pennsylvania radiation oncologist Gary Kao, who was involved in 91 of the incorrect procedures, from agency-related activities unless he undergoes training and meets other requirements.

The agency also ordered medical physicist Gregory Desorby, an independent contractor who it said was involved in most of the cases with errors, to notify the NRC if he accepts employment that entails NRC-related activities. Both orders take effect after 20 days.

Attempts to reach Kao for comment Wednesday night were unsuccessful, and calls and an e-mail message to his lawyer, Jack L. Gruenstein, were not immediately returned. Desorby said he had no comment.

The Philadelphia VA shut down its brachytherapy program in 2008, and neither man is currently working for the VA, a spokesman said.

Kao is a researcher, with no clinical contact, at the University of Pennsylvania School of Medicine.

"There was no indication that his research was at all compromised by these other issues," Penn spokeswoman Susan E. Phillips said.

Although the VA's brachytherapy program ended, Phillips said, Penn remains "partners" in other pursuits with the VA.

Strengthening the relationship with Penn is a priority of the VA's director, Joseph Dalpiaz, spokesman Dale Warman said. Dalpiaz arrived in October after what Warman said was his predecessor's unrelated retirement.