In recent months, reports from the Nuclear Safety Authority (ASN) concerning errors in processing in radiotherapy of several cancer patients, have multiplied. There external radiotherapy is a treatment technique using ionizing radiation generated by a particle accelerator to destroy cancer cells, which is administered to the area to be treated over several sessions.
On March 25, 2024, ASN was notably alerted of a Laterality error during treatment of breast cancer by external radiotherapycarried out at the greater Montpellier cancer center. “Eight treatment sessions out of the twenty-five planned were thus carried out on the wrong side”explains the agency in a press release, that is to say that there was an inversion between right and left during the preparation and execution of the treatment. “The error was detected during a weekly follow-up consultation, due to the appearance of side effects on the side opposite to that of the tumor”, added ASN.
External radiotherapy error: what are the consequences for the patients concerned?
But this event is not an isolated case. A few days later, on March 27, the Nuclear Safety Authority was informed of another laterality error, which occurred at the Burgundy Cancer Institute in Dijon, where a patient underwent 20 sessions, almost all of her treatment, on the wrong side.
For these two external radiotherapy treatment errors, “taking into account the overdose of the wrongly treated region, and the potential risk of side effects, ASN classifies this event as level 2” severity, out of 7. “We consider that‘there are no after-effects or loss of opportunity as regards the delay in treatment of pathological breast”, added the radiotherapist oncologist at the Dijon cancer institute, Édouard Lagneau, in an interview with France 3 Bourgogne-Franche-Comté. But he added that “on the other hand, there is psychological trauma, yes”.
The Nuclear Safety Authority invites health establishments and professionals to be extra vigilant
Following these reports, the two establishments concerned must provide the Nuclear Safety Authority with reports to understand the causes of these errors, as well as the planned corrective measures, which will subsequently be verified by the ASN. as part of its control activities. Indeed, the objective is to understand how these errors could have happened and not been corrected, so that they do not recur. “ASN notes the increase in this type of error and calls again the attention of professionals radiotherapy on the need to evaluate the robustness of the safety barriers put in place to protect against laterality errors”, concludes the agency. However, it should be remembered that these radiotherapy treatments are always subject to numerous checks and that such errors represent only a tiny part of them.
Sources :
- Laterality error during external radiotherapy treatment – Nuclear Safety Authority – 04/23/2024
- Side error during external radiotherapy treatment – Nuclear Safety Authority – 04/10/2024
- INTERVIEW. Medical error in Dijon: how could the cancer institute have the wrong breast when treating a patient? – France 3 Bourgogne-Franche-Comté – 04/24/2024
