No. III-08-040 

Contacts: 

Viktoria Mitlyng 630-829-9662 

Prema Chandrathil 630-829-9663 

 October 15, 2008 

 E-Mail: opa3@nrc.gov 

Web site: www.nrc.gov

NRC ISSUES CONFIRMATORY ACTION LETTER 

TO THE DEPARTMENT OF VETERANS AFFAIRS 

 As a result of errors in the prostate cancer treatment program at the Veterans Affairs 

(VA) Medical Center in Philadelphia, Pa., and suspected errors at other facilities, the Nuclear 

Regulatory Commission said Wednesday it has issued a confirmatory action letter to the 

Department of Veteran Affairs National Health Physics Program.

 The letter documents the commitments made by the Department of Veterans Affairs to 

identify and address the problems that have led to medical errors at VA hospitals and to prevent 

their recurrence. The NRC will verify through inspections that the items in the confirmatory 

action letter have been successfully completed. The VA will not restart its suspended cancer 

treatment programs until these commitments have been met. 

 The Department of Veteran Affairs National Health Physics Program commitments 

include: 

• conducting inspections at all 13 VA hospitals authorized to perform prostate cancer 

treatments; 

• developing and implementing standardized procedures for prostate cancer treatments at 

all VA hospitals; 

• identifying causes of the medical events and implementing corrective actions; 

• suspending any prostate cancer treatment program where 20% or more treatments have 

been identified as medical events; 

• conducting an inspection to confirm that all necessary corrective actions have been taken 

prior to restarting any suspended cancer treatment program; 

• notifying the NRC when program restart is planned; 

• conducting an inspection of new prostate cancer treatment programs to confirm they meet 

the enhanced standards. 

 “The health and safety of US veterans are of paramount importance to the Nuclear 

Regulatory Commission. Facilities that use nuclear materials for medical treatment have a 

responsibility for administering treatments properly and safely,” said Regional Administrator 

James Caldwell. “The confirmatory action letter will help us ensure that problems that led to 

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medical errors at VA hospitals are addressed and that actions are taken to prevent their 

recurrence.” 

 This issue first came to the NRC’s attention in May 2008, when the Department of 

Veterans Affairs National Health Physics Program notified the Nuclear Regulatory Commission 

that the radiation dose delivered to a patient at the Veterans Affairs Medical Center in 

Philadelphia, PA, to treat prostate cancer was more than 20 percent lower than the prescribed 

dose. 

 Prostate cancer treatments involve implanting iodine-125 seeds of a prescribed radiation 

dose into the patient’s prostate. 

 The medical center’s review of all other prostate cancer treatments at the facility had 

identified 92 medical errors out of the total of 116 treatments conducted since the inception of 

the program in 2002. 

 In response, the NRC launched a special inspection to examine circumstances that led to 

multiple medical events during radiation treatments of prostate cancer in VA Philadelphia. 

Another goal of this inspection was to determine if the problem at the VA Philadelphia medical 

center exists at other VA facilities with similar programs. 

 The VA has since told the NRC of additional problems at three of its 12 other facilities: 

Cincinnati, Ohio, Jackson, Miss., and Washington, D.C. The VA hospitals at these locations and 

in Philadelphia suspended their programs. The Department of Veterans Affairs will not resume 

its prostate treatment programs until its commitments to enhance these programs have been met. 

 The NRC’s ongoing special inspection is tasked with conducting independent inspections 

at several Veterans Affairs hospitals; evaluating the response of the Department of Veterans 

Affairs National Health Physics Program to the medical events and their investigation; and 

accompanying National Health Physics Program inspectors on inspections of VA hospitals to 

review their activities. In addition, the Nuclear Regulatory Commission hired an independent 

medical consultant to examine possible health effects to patients. 

 The 13 VA hospitals with prostate cancer treatment programs are in: Albany, N.Y., 

Boston, Mass., Brooklyn, N.Y., Cincinnati, Ohio, Durham, N.C., Jackson, Miss., Los Angeles, 

Calif., Minneapolis, Minn., Philadelphia, Pa., Richmond, Va., San Francisco, Calif., Seattle, 

Wash., and Washington, D.C. 

 The NRC will issue two special inspection reports. One will address the medical events at 

the Veterans Affairs Medical Center in Philadelphia; the second report will address findings at 

other VA facilities. The Department of Veterans Affairs National Health Physics Program will 

submit a letter to the NRC after all the commitments in the confirmatory action letter have been 

met. Both reports and the VA letter will be available through the NRC RIII Office of Public 

Affairs and at the NRC web site: http://www.nrc.gov/reading-rm/adams/web-based.html. 

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