It’s the kind of story that can’t help but be compelling:
As 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.
Sensing death was near, Mr. Jerome-Parks summoned his family for a final Christmas. His friends sent two buckets of sand from the beach where they had played as children, so he could touch it, feel it and remember better days.
Mr. Jerome-Parks died several weeks later in 2007. He was 43.
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.
The story, titled “Radiation Offers New Cures, and New Ways to Harm,” appeared Sunday in the New York Times and has generated some intense online discussion and blog commentary.
Therapeutic radiation is commonly used to treat cancer; more than half of all people diagnosed with cancer will at some point receive radiation therapy. The technology has come a long way over the past couple of decades. Treatment is typically more targeted than it used to be, so healthy cells can be spared the collateral damage of radiation exposure. Refinements such as intensity-modulated radiation therapy, or IMRT, also are increasingly being offered to patients.
But it carries its own set of risks – risks that patients are often uninformed of, and that may not be adequately addressed by the industry. Furthermore, the increasing use of complex equipment, software and treatment protocols is raising the danger that errors will occur and patients will be harmed, the New York Times explains:
“Linear accelerators and treatment planning are enormously more complex than 20 years ago,” said Dr. Howard I. Amols, chief of clinical physics at Memorial Sloan-Kettering Cancer Center in New York. But hospitals, he said, are often too trusting of the new computer systems and software, relying on them as if they had been tested over time, when in fact they have not.
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.
Many readers who commented on the story were appalled. “I could not finish reading this piece. It was an eternity of agony, even to get halfway through the narrative,” one person wrote. “Horrifying,” wrote someone else.
I count at least five separate and significant issues explored in the article and in the accompanying pieces: 1) the inherent risks of medical radiation; 2) the potential for medical devices to fail, especially as they become increasingly complex; 3) staff competence; 4) appropriate safeguards, checks and balances to ensure patient safety; 5) public accountability by the health care industry to investigate and prevent errors such as the one that killed Scott Jerome-Parks.
Although there’s been increasing focus on the risks associated with radiation exposure from routine CT scans and X-rays, I question whether it’s a fair comparison to therapeutic radiation. Radiation therapy has a specific intent, to treat cancer, so a whole different set of issues comes into play when making decisions whether to subject a patient to therapeutic radiation. Obviously, the amount of radiation required to target a tumor is also far greater and exposes the patient to significantly more radiation than any CT scan, albeit for the purpose of treating a serious disease. It can be a difficult tradeoff for cancer patients, who must weigh the potential risks of radiation treatment against the likelihood of the benefit.
If I were a cancer patient, I’m not sure how I would react to the New York Times story. Indeed, a number of commenters accused the reporting team of sensationalizing the issues and possibly scaring patients into making wrong-headed decisions. One person wrote:
While it is important to appreciate errors in medicine and swiftly correct them, particularly in an age of increasingly complex and computerized equipment, this article does a very effective job at frightening readers, particularly those with a personal experience of cancer therapy. The impression the reader takes is that there is gross negligence running rampant throughout radiation oncology departments as a matter of course. The article fails to mention the quite rigid quality assurance regulations in place for hospitals and physicians at the state and federal levels. This is a highly regulated field – not one of no oversight.
The American Society for Radiation Oncology issued its own statement this week, asserting that radiation therapy is still safe and effective and that errors are rare. A science blogger and cancer researcher offers his own take, drawing parallels between radiation therapy safety and surgical safety:
Reducing medical errors that harm patients is about more than just physicians. It’s about the whole system. In surgery we have been discovering this (and struggling with it) over the last decade or so. It’s not enough to just target the physicians. In my specialty and in the operating room, it’s necessary that everyone be involved, from the nurse who sees the patient when he comes in, the physicians who do the surgery, the scrub techs counting instruments, the scrub nurse verifying surgical site – in essence everyone involved with the care of the patient from the moment he shows up for surgery to the moment he either goes home or is admitted to the hospital. Radiation oncology has at least as many people involvedÂ in the care of the patient, if not more: nurses, radiation physicists, radiation oncologists, technicians operating the machinery. Moreover, because unlike surgery radiation is often given in small fractions over many visits, there are many more opportunities for error than in surgery.
Ultimately, I think the reporting by the New York Times has done a major favor on behalf of patient safety. At one time, chemotherapy errors were rarely publicized and efforts to make this form of cancer treatment safer were occurring mostly in piecemeal fashion. This all began changing in the mid-1990s, after the death of Boston Globe reporter Betsy Lehmann, who mistakenly received a lethal overdose of a chemotherapy drug. There’s now much greater awareness within the oncology community about medication safety, and a growing body of literature on chemotherapy administration procedures that have been shown to be safe and effective.
I’m not sure if this has been happening in radiation oncology to the same extent. A good start would be to develop a set of quality criteria – and to share them with the public, so patients and families can be better informed and in a better position to ask questions and advocate for themselves if something doesn’t seem right. It’s also essential to report errors and close calls in order to analyze what happened and redesign processes or systems to make them safer. After all, if you aren’t tracking mistakes, it’s nearly impossible to gauge how often they occur and what the contributing factors might be. Finally, there appears to be a need for more oversight – not just of hospital programs but of how the equipment and software are designed and manufactured and how the people who operate it are trained.
Injuries and deaths related to radiation therapy might be rare, but this is small comfort to patients and families who’ve had it happen to them. Surely the industry owes it to these people to do its best to be safe and accountable.
Photo: linear accelerator, Wikimedia Commons