NYT article on radiation mistakes/overdoses - very scary

[bejuce]

An article posted on the New York Times web page yesterday exposed some appalling mistakes committed during radiation treatments. Patients were given huge overdoses of radiation that ultimately led to their death. I read the article (click here (http://www.nytimes.com/2010/01/24/health/24radiation.html?em)) last night and have been thinking about the patients and their families ever since. So much so that I felt out of sorts today, stressed, emotional, angry, a mixed bag of emotions all rolled into one.

I thank the New York Times for telling us the story. Hopefully the lives that were lost to the medical/technical mistakes committed will bring new levels of oversight in radiation rooms everywhere.

[Audrey]

I read this article yesterday, too, and was horrified and upset. I hope it doesn't discourage people who need radiation from getting it, but it sure is scary to read about all the mistakes--

[Margerie]

Horrible! My own radiation experience was not good... on my first consultation the nurse MADE me watch "an educational video about breast cancer" It was 30 minutes promo on why lumpectomy was so much better than mastectomy. Problem was I had had a mastectomy 3 months before this appointment (at the age of 38) and it was not elective. I was so pissed that I chewed out the radiation oncologist for 15 minutes. I mean if these people can't even read your chart to see why you are at their office in the first place, how are we supposed to trust them to computate how much radiation we should have and how it will be delivered? Sometimes I think it is a miracle anything ever gets done right.

I am thankful for this article, these horrible mistakes should not be kept from the public.

[AlaskaAngel]

One would like to think that medical providers are that conscientious about us. We see an onc or doctor that hopefully we have some trust in, and then they send us to the rads department, but who is really tracking this?

Sorry to be redundant for those of you who have seen my posts about this before, but unfortunately the concern about various aspects of radiation is genuine. My own personal experience includes an episode when the CT technician conducted the CT on me and then came in and told me it needed to be repeated. I should have refused, but I relied on her training and let her repeat it. The result was that for 3 days following that, I had radiation sickness. Even more disturbing was that both CT exposures I had were not done as part of a checkup out of necessity, but were both optional and were done in order to qualify for a clinical trial I was interested in.

Here is some info for consideration about the status of radiation facilities:

Radiation from health scans causes concern

Increasing use stirs cancer fears

By LAURA GEGGEL (laurageggel@seattlepi.com)
P-I REPORTER

(Editor's note: This story has been changed since it was first published. The previous version incorrectly stated that Magnetic Resonance Imaging uses radiation.)

Cheryl Smith's cancer went into remission after her mastectomy two years ago, but she travels from Port Angeles to Seattle annually so doctors at Virginia Mason Medical Center can scan her to check for a relapse.

Last month, she had her second CT scan, four years after she was diagnosed with late-stage breast cancer. She said the radiation exposure from the scan is hardly a major concern for her.

"I think about it once in a while," said Smith, 58, but she noted that people flying around the world regularly receive relatively high levels of natural radiation40,000 feet closer to the sun.

But Smith's CT scan subjected her to nearly 300 times the radiation she would have received on a roundtrip, coast-to-coast flight, according to data from the AmericanCollege of Radiology.

Americans are being exposed by scans to record amounts of ionizing radiation, the most energetic and potentially hazardous form of radiation. Some researchers are concerned not only that the procedures are being overused, but also that patients may have no idea how much radiation they are receiving. Some physicians are worried that increased radiation exposure could lead to higher cancer rates.

"A CT scan of the chest will give you about the same radiation dose to the breast tissue as 10 to 20 mammograms," said Dr. Fred Mettler Jr., professor emeritus of radiology at the University of New Mexico and representative to the United Nations for nuclear radiation effects.
"Most women don't have a clue," he said. "Most people would get up and leave if they knew that."

Mettler is the principal investigator for the National Council on Radiology Protection's report on sources and magnitude of radiation exposure in the United States. Funded by the Nuclear Regulatory Commission and the Environmental Protection Agency, the report is expected to be published early next year.

Most radiation exposure previously came from natural background radiation. While advances in radiology have radically transformed medical practice and allow pinpoint diagnostics and treatment, they also have meant that more people are getting more radiation.

Clinical imaging exams in the United States are largely responsible for the per capita dose of ionizing radiation increasing almost 600 percent from 1980 to 2006, concludes the new report.

Though CT scans make up only 12 percent of all medical radiation procedures, they deliver 46 percent of the total dose of radiation exposure in the United States, Mettler said.

The report found that the number of CT scans jumped from 3 million in 1980 to 62 million in 2006. Mettler called the increase "staggering." He said that amounts to about one CT scan a year for every five people in the United States.

No one is saying that CT scans should be eliminated. However, researchers such as Mettler believe the Food and Drug Administration should take a more active role, and that patients need to be better informed about radiation doses.

Despite their high radiation, diagnostic radiation machines are not regulated by the FDA. Only mammogram facilities must be periodically accredited by the AmericanCollege of Radiology to qualify for Medicare funding.

Other countries do have regulations. The United Kingdom requires hospitals to carry out periodic dose audits to show that the mean radiation doses for the entire hospital do not exceed national reference levels.

"The Europeans are ahead of us in this area in measuring dose and making people more aware of what the risks are," said Dr. Brent Stewart, a professor of radiology at the University of Washington. "The AmericanCollege of Radiation is taking a very progressive stance in implementing these ideas of dose consciousness. We need to do more to raise the consciousness of referring physicians."

The radiology department at Virginia Mason employs precautions when it comes to CT scans, checking if the patient has had a CT scan at another hospital within 24 hours and sometimes questioning the size of the requested scan. Radiology technologists also give women 70 and younger a breast shield that deflects a percentage of low-dose radiation known to linger in breast tissue.

"We generally don't use CT scans unless there is a life-threatening condition," said Giao Nguyen, an emergency room doctor at Virginia Mason.

"When you image a patient, you're trying to answer a question," said Dr. Marie Lee, a radiologist at Virginia Mason. "You want to be sure that the question you're asking can be answered by the radiation."

Lee compared the images produced by a CT scan as akin to looking at a detailed anatomy textbook, but cautioned that radiation in larger amounts can have complications that may lead to cancer.

Stewart said that the University of Washington Medical Center and HarborviewMedicalCenter are trying to implement an electronic order entry system that would allow physicians access to radiology guidelines and show how frequently patients are receiving radiation.
Stewart offered patients some advice.

"The patient, as a good consumer, ought to know as much as possible and ask as many questions as they need to be satisfied," he said.

Like driving on the highway, he said, using medical radiation involves risk.
Radiologists are still studying the correlations between medical radiation and cancer rates. A 2004 study in The Lancet surveying data from 1991 to 1996 suggested that medical radiation accounts for only 1 percent of American cancer cases, but a May 2007 report from the AmericanCollege of Radiation stated that most radiation-induced cancers can take 10 to 20 years to occur.

Stewart said there is still some debate about the carcinogenic effect of medical radiation

"At this point, we don't know for certain whether small doses of radiation like chest X-rays are injurious to a person overall," Stewart said.

But Mettler wants more safety precautions in place. Radiation doses for the same procedure can vary in the hands of different practitioners by as much as a factor of 10, reports the FDA. He would like to see the FDA actively involved in pressuring manufacturers to use lower radiation doses that still produce good images.

"There's a huge amount of pressure to order these things, but people just don't know how much radiation there is," he said.

SCANS


CT, or Computed Tomography, scans take a series of X-ray slices of an area of concern. A computer combines the slices to form a multidimensional view. Dyes, each highlighting separate soft tissues in the body, such as blood vessels or the colon, show up in shades of gray on the resulting CT image.

Carrie Richardson, a radiation technologist at VirginiaMasonMedicalCenter, said the denser areas are grayer: "The overall density of a healthy organ should be all the same tone." If an organ appears to be different hues, physicians may order a biopsy.

Magnetic Resonance Imaging also captures images of patients using non-ionizing radio waves. But MRIs require more time than CT scans, provide less detail and cannot portray motion as well.

An additional Oncolink article about CT risks:

http://www.oncolink.org/resources/article.cfm?c=3&s=8&ss=23&id=14806&month=11&year=2007 (http://www.oncolink.org/resources/article.cfm?c=3&s=8&ss=23&id=14806&month=11&year=2007)

[AlaskaAngel]

P.S.

Again, in this sophisticated computerized medical world, why are providers thus far incapable of managing to create the same kind of badge for patients that they use with members of the staff to keep a cumulative running dose actually received by each individual, so that there is some reality to what is known and what is not about radiation exposure and its hazards?

Maybe if patients were to ask that question every time they get near a radiology employee, over and over, somebody might get it together for us?

A.A.

[StephN]

Great to see more articles on this subject.
The thing that strikes me about getting people to recognize the danger, is that the test is so SHORT. You lie down on the table, get positioned, hold your breath a couple of times and then they help you off the table.

How could this be putting us in any danger?? This is a quick and easy test to see if I am OK or not. This is what we stage IV patients have to keep track of our tumors.
The longer we live, the more scans we have in the name of monitoring our disease.

I mentioned the idea of a "radiation" badge to a professional at my cancer center. One thing is that the patients would not be able to wear it in the machines. Since we are out of the presence of the machines the rest of our lives, the badge would only be able to measure the ambient radiation we contact in our daily lives. That is so minimal compared to the scans, that there would be no real value.

That person suggested that if we can get a consistent number for the radiation we are exposed to in the various tests from regular audits as suggested in that article, that can be kept track of and might actually become part of our medical record.

A.A. - you are in the medical records type work, so what do you think of this as a way to keep count, like they have our other labs and vitals charted?

[AlaskaAngel]

Hi StephN,

Personally I think just about anything would be an improvement in moving toward a better grasp of the hazards by everyone concerned.

But in going back to the original post (regarding machines and personnel carelessly or unknowingly giving excess doses), just using a supposedly accurate or roughly accurate count by type of procedure wouldn't help. The technician would just write down that number rather than the actual real dose that was given.

I think that if the designers of these machines are smart enough to figure out how to create a machine that does all these magnificent things, they are smart enough to devote some attention to making sure it measures how much is being given WHILE it is being given, including automatic bells and whistles that go off if it exceeds the safe amount, and even maybe something that triggers it to shut off if it approaches the maximum of the proper dose.

I do think a major part of the problem exists not only because of rogue excess doses, but because no one has consistently been tracking the doses. If they aren't currently collecting that data for patients, how accurate are their beliefs in what is too much or enough or too little?

On a practical basis, whatever it is really should be something that goes with the patient. Here (like every other tourist destination) we get patients from every mode of transportation (probable and improbable) and they don't carry squat with them for health records when they suddenly find their way to the radiology department.

If just individual areas of the body are receiving the radiation, then whatever the tracking device is, would have to be in each field of radiation that is exposed. But I believe it might be possible for the machine itself to measure a "spot" of the actual radiation that the machine is dispensing at the time it dispenses it no matter what part of the body is receiving it, and automatically record that on the digitized patient record for each exposure.

But it takes inventors and consumers (patients) to pursue it.

[Margerie]

I googled just now to see if there was any follow up on this article today and didn't find anything except the injury attorneys have already jumped on it.

I did find a report done a few months ago by the Patient Safety Authority in Pennsylvania. There is a lot of info on radiation safety and risk reduction strategies. Looks like some great references at the end of the article.

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Sep6(3)/Pages/87.aspx

[AlaskaAngel]

Thanks, Marjorie for sharing that. The best articles on this topic seem to originate in Pennsylvania, which is where Oncolink is based. They seem to be trying to identify problems and come up with good answers for them, as well as providing cautions for patients to consider.

I still think that providing the patient's permanent record with some method of continous "counting" of every actual dose delivered (regardless of the reason for delivering it correctly or incorrectly) is in the patient's best interest, because the description of the monitoring they are discussing is limited to whether the dose given at one instance is correct or not. That means the patient can still end up having too much radiation by virtue of having too many procedures. For example, in my situation I have been seen and treated for breast cancer in Alaska, Seattle, and California with radiation and none of these places routinely are provided with information to help them decide whether or not I might be at a point where more radiation should or shouldn't be done.

For that reason I made a personal list of every single exposure I have had with dates and types of procedures and gave a copy of it to my PCP here in Alaska. They had no information from the Seattle institution about the double CT exposure, or about the episode of radiation sickness. They simply had no current total of radiation received thus far. And there are no "rules" for them to follow other than their own concern for me in trying to decide whether or not to order more radiation to help them figure out what is going on versus a few repeated lab tests, or perhaps using ultrasound even when it might not be quite as useful but would be less damaging.

A.A.

[bejuce]

If anyone is interested, the NYT had readers post their comments to the article in this link here (http://well.blogs.nytimes.com/2010/01/23/when-radiation-treatment-turns-deadly/?ref=health) - some of them describe additional cases of overdoses, others describe errors, and so forth.

The lesson again for me is that patients always need to either be their own advocates or have other advocates with them. I remember looking at the computer screen at every radiation session and making a mental note of the numbers and settings to pay attention whether anything was out of sorts. Medical mistakes happen all the time - it happened with me - and unfortunately, we cannot always count on the doctors and nurses to correct them.

I had my radiation sessions (5 1/2 weeks) at Stanford, and there were usually 2-3 therapists in the room, never just 1. I was seen by my radiation oncologist every Thursday, and by her resident every Wednesday after the sessions to examine me, my skin, and discuss whatever else was on my mind. Not sure if patients elsewhere get to see their doctor and resident every week but it sure helps to have as much oversight as possible.

I happened to be radiated on a Varian machine (not sure what kind) and literally work right behind their company headquarters in Palo Alto. Maybe I should just invite myself over there one of these days to talk to Varian engineers designing the machines to put all sorts of alarms, interrupts, and so on, to prevent those mistakes from happening. This may sound naive, but hey, we have to try everything to improve our treatment and that of others going through this...

[krisvell]

Thank you for sharing. Reading the article really took me a back. I have 8 more Radiation treatments to go. I hope they did it correctly. I will be more aware of the monitor in the room to ensure they line me up to the plan coordinates. I'm also going to check to see what kind of machine it is.
Kris....

[CLTann]

I have long outcried about the radiation danger. I am certainly outraged for the 1,000 dollar fines to two New York based hospitals for their errors. They are what the patients' lives worth?

A simple cumulative badge assigned to all patients with estimates of missing doses prior to the badge issuance should at least give all, both patients and medical providers some clue on how close the patients are near the maximum cumulative dosages.

How many patients need to die before the medical circle adopts such a simple device?