The Radiation Safety Institute of Canada says it has been contacted with concerns following an announcement that 25 women with cervical cancer may have received faulty radiation therapy at a Hamilton hospital.
On Jan. 3 the Juravinski Cancer Centre (JCC) announced that 25 cervical cancer patients may not have received radiation in the exact location of the body where it was intended due to a “guide tube” that was longer than it needed to be.
Dr. Curtis Caldwell, chief scientist at the RSIC, based in Toronto, says this has sparked concern.
“All that we can say is that there’s a number of people concerned within Ontario.”
I don’t think this is a systemic problem that we’re looking at here– Dr. Curtis Caldwell, chief scientist, Radiation Safety Institute of Canada
The RSIC is an independent non-for-profit national organization dedicated to promoting and advancing radiation safety in the workplace, in the environment and in the community. It receives calls and emails from people concerned with radiation safety issues.
Caldwell says a few people have been in contact with a broad range of questions relating to radiation therapy, with some asking if all BT procedures would be at risk, or whether the error only occurred in Hamilton.
The questions aren’t necessarily those of cancer patients, or from those involved with the treatment at the JCC, but from friends and family of cancer patients in general, and just curious people, he says.
“They’re totally unrelated to be honest, from a point of view of risk because they’re concerned that there’s a problem with the medical system I guess, which is concerning to me because I was a medical physicist for many years — and I don’t think this is a systemic problem that we’re looking at here,” said Caldwell.
Ralph Meyer, vice president of oncology and palliative care and regional vice president of Cancer Care Ontario, told CBC News Jan. 4 the issue was discovered Nov. 27.
He says while in the process of providing treatment that day, unrelated to the issue that was discovered, there were some irregularities that occurred in setting up for the treatment.
“That caused the team to pause and do a total quality assessment of the system, and it was discovered at that time that what’s called a guide tube was longer than it should have been,” said Meyer.
“We have done quality assurance processes in the past and the tube measured as it should. Why it has changed we don’t understand at this point. There will be ongoing evaluations to understand that,” said Meyer.
We’re extremely disappointed and our hearts go out to these patients– Ralph Meyer, vice president of oncology and palliative care and regional vice president of Cancer Care Ontario
Hamilton Health Sciences says it has replaced the BT equipment and paused the specific therapy at the JCC while external experts conduct a review of their radiation therapy program.
While the review is being conducted, new cervical cancer patients needing BT will be transferred to the London Regional Cancer Centre.
It says no other patients at the JCC are affected.
Because of privacy issues, Meyer can’t say whether or not any patients died during the time period when the longer equipment was used.
Meyer says all 25 patients involved have been notified and been given apologies.
“There’s been a range of reactions,” said Meyer. “There are some patients who understandably are reacting with surprise and disappointment and have communicated to us a feeling of a breach in trust and we understand that and we apologize for that.”
“We’re extremely disappointed and our hearts go out to these patients. We have tried to be as open and honest and accountable to them as we possibly can, and we’ve apologized to them,” said Meyer.
Radiation in the wrong location
There are two dangers associated with radiation hitting the wrong location according to Caldwell.
The primary danger being that treatment may not be delivered to the correct location.
The second he says, is that normal cells could be killed instead.
“I think it’s extremely rare that it actually impacts a patient,” said Caldwell about “near-misses” with radiation therapy.
Caldwell says he hasn’t seen any reports relating to the case in Hamilton, nor is he involved with the review at the JCC, but says some parts of the vagina could potentially have had too high a dose of radiation.
“Distance is a really crucial thing in this case so you would hope that there wouldn’t be a terribly high dose to the vagina walls, but there (was) certainly potential for damage to those cells.”
He says what’s helpful to the Canadian health system is the Canadian Partnership for Quality Radiotherapy. It’s a national system for reporting radiation treatment incidents.
Caldwell says the reporting system is a useful tool to prevent potential future incidents.
“I know it’s a bad news story for these 25 individuals and their families, but it can be a good news story for the way we improve radiation therapy in Canada for everyone else and make it safer,” said Caldwell.