Investigations found poor outcome for patients with deep-seated tumours

Younten Tshedup  

An investigation carried out on the radiotherapy services at the Thimphu national referral hospital (JDWNRH) has found that the radiation treatment offered at the hospital has not benefited patients with deep-seated tumours, resulting in poor treatment outcome.

A preliminary clinical report written on the investigation looked into the effectiveness of the service. According to the report, it was noticed that patients with deep-seated Stage III rectal tumours who were sent for tumour downsizing in preparation for surgery were not obtaining the optimal response normally seen after radiation. This was first observed in 2019 in 12 rectal cancer patients almost one year after the introduction of the services.

Earlier this March, the hospital management was informed of the increasing mortality (death) among cervical cancer patients after the start of radiotherapy services at the hospital.

The issue 

Concerns regarding the quality of radiotherapy service at JDWNRH were first raised to Care Australia, an international aid organisation operating the radiotherapy services at JDWNRH, in February 2018. However, Care Australia made assurances at the time that the service was as per international standards.

Following the high mortality rate among cervical cancer patients, despite receiving radiotherapy treatments, the oncology department conducted a three-day mortality data analysis in June 2021. The inquiry found out that the existing radiotherapy machine needed upgrading.

Several other issues were found when the Ministry of Health and JDWNRH reviewed the service agreement between Care Australia and the hospital management on the introduction of radiotherapy services.

As per the investigative report, basic requirements for the establishment of new technology in the country were not followed. Section 8.4 of the National Health Policy 2011 states that no new health technology will be allowed until assessment and evaluation for its safety, efficacy, quality, indication, and cost effectiveness have been conducted by the health technology assessment panel.

It was also found that due process for executing any memorandum of understanding or agreement with external agencies in line with the Rule of Treaty Making Procedure 2016 was not conducted. They also lacked due diligence as per the Procurement Rules and Regulation.


A possible scam?

In principle, the approval to introduce radiation therapy service at JDWNRH was given in May 2016. Prior to the approval, a doctor from Care Australia made a comprehensive presentation on the modality of setting up the radiation therapy service at the hospital.

A team comprising senior officials from the Ministry of Health, JDWNRH, and Khesar Gyalpo University of Medical Sciences of Bhutan (KGUMSB) reviewed the service agreement. Following the review, the service agreement was signed on June 17, 2016 with no feedback from the board.


More issues      

The investigation found that the health technology assessment (HTA) was not conducted during the pre-installation phase as there were no records of it. Local technical experts found during a detailed analysis of the radiation therapy machine that the machine was producing only single photon energy with low energy, which caused suboptimal outcomes when treating deep-seated tumours.

It was also found that the machine did not produce the level of electron energies required for treating superficial cancers. The technical investigation found the need to upgrade the radiation therapy machine at JDWNRH.

Meanwhile, since August of this year, all cancer patients are now referred to India for radiation except for palliative patients. In a meeting held last month, chaired by the health minister, they decided to keep the radiation services on hold (both curative and palliative treatment).

It was learnt that a notification was issued to Care Australia on September 21 this year communicating the issues. JDWNRH received a response from the company on October 1. Kuensel was not given access to the report.

Meanwhile, Lyonchhen Dr Lotay Tshering said that a presentation on the issue was due last week but could not take place. 

Kuensel learnt that a preliminary report  of the investigation was presented to the health minister. The team from JDWNRH is expected to present the findings to the ministry’s high level committee which will deliberate and propose recommendations before submitting the report to the Cabinet.