The Juravinski Cancer Centre has suspended a specific cervical cancer treatment, referring cases to a patient cancer centre in London, Ont., after an equipment issue might have resulted in mistargeted radiation in as many as 25 women.

The JCC and Hamilton Health Sciences are conducting a system review following the discovery that a guide tube used in brachytherapy (BT), in 2017 and 2018, was the incorrect length.

The length discrepancy might mean the radiation did not always reach the exact point intended. All 25 of the patients who received BT for cervical cancer in those two years have been identified, notified and met with, said Dr. Ralph Meyer. No one else is at any risk.

"We have apologized to them and their families," said Meyer, HHS vice-president of oncology and palliative care and regional vice-president of Cancer Care Ontario. "We deeply regret that this occurred. Everyone at the JCC is committed to providing treatment that is effective and safe. We will evaluate our processes thoroughly and remedy any gaps in our care."

Some of the 25 have been undergoing tests and will undergo more, including CT scanning, and possibly MRI and/or PET scanning, said Meyer. The tests, he explained, are meant to help staff assess how well the patients' cancers are being "controlled" and whether there are "side effects" of the radiation in question.

It is too early to tell, but side effects of the equipment issue could conceivably include "radiation injury or damage to the vagina and the area around the vagina," said Meyer.

But, he cautioned, it might be difficult to determine which outcomes can be linked to the equipment issue when they might be outcomes that "can occur even when treatment is given under ideal conditions."

"As we move forward we've completed some statistical analyses but it is important to be very thorough; it is hard to come up with patterns," with a relatively small number, for statistical purposes, of cases.

Those overseeing the patient care plans will be monitoring for outcomes or patterns "different from what we'd expect."

Meyer explained that on Nov. 27, 2018, the team responsible for brachytherapy noticed the wrong guide tube length while investigating another equipment issue, one which was successfully resolved.

"We have subsequently been evaluating the entirety of the system. The equipment (in question) has been taken out of service, and all types of brachytherapy are being reviewed." The system review process includes external experts.

"We are still trying to understand why the guide tube lengths (taken in November) differed" from those taken when last measured before, at which time the lengths were correct.

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"We want to assure everyone that this is an aberration, and the rest of our program is strong, effective, safe and high quality."