[ RadSafe ] New York Times story on radiation therapy errors

William Lipton doctorbill34 at gmail.com
Wed Dec 29 10:54:48 CST 2010

I recommend the following story:
http://www.nytimes.com/2010/12/29/health/29radiation.html?hp regarding
treatment errors involving therapy with linear accelerators.

I have a comment and a question:

comment:  There seem to be two root causes:  (1) the ill-considered
retrofitting of a linear accelerator for use as a gamma knife - This
involved error prone data control procedures, with treatment planning
performed on one computer system, and then transferred to the control
system, sometimes via flash drive.  The linac was not used as designed, and
the potential errors with the new use were not adequately evaluated.  (2)
the lack of proper reporting requirements - This allowed the same errors to
be repeated at multiple sites, since users were unaware of the problems.
FDA regulations seem to be less than adequate, here.

question:  Many of the treatments were for benign conditions.  I thought
that ICRP guidance specified that radiation therapy should only be used for
cancer treatment, since the risk versus benefit equation was not favorable
for benign conditions.  The consequences of some of these errors are
horrendous, e.g., a 50 year old women who had an unpleasant, but not life
threatening condition is now in a persistent vegetative state.  Has this
recommendation been superseded?  (I remember one personal event, in the
1950's.  My sister had a growth on her eyelid.  The ophthalmologist
recommended radiation therapy.  My father's healthy skepticism made him say,
"no thanks."  BTW - the growth went away without treatment.)

Bill Lipton
It's not about dose, it's about trust.
doctorbill at post.harvard.edu

More information about the RadSafe mailing list