Breasts treated incorrectly during radiotherapy: Nuclear Safety Agency warns of ‘increase in these types of errors’

The Authority for Nuclear Safety (ASN) recently warned of an increase in “lateral bias” in the context of breast cancer treatment with external beam radiation therapy, that is, inversion between right and left during the selection of the organ to be treated.

Recently, administrative authorities have recorded several incidents. The most recent case, reported on April 23 but dating back to March 25, occurred in Montpellier, at the Cancer Center of Greater Montpellier (CCGM). The patient was treated on the wrong breast during eight of the twenty-five originally planned radiation treatments. “The error was identified during the weekly follow-up consultation, given the occurrence of side effects on the side opposite the tumor,” ASN points out.

20 sessions about sore breasts

A few days earlier, a patient at the Burgundy Cancer Institute (ICB) in Dijon fell victim to a similar error. She had 20 sessions or all of the treatment on the wrong breast. The error was noted during a follow-up consultation after treatment.

According to Édouard Lagneau, radiation oncologist at the Dijon Cancer Institute, in an interview with France 3 Bourgogne-Franche-Comté, the patient once reported a mistake, but she was not listened to and did not dare to speak about it again. “At this stage, the treatment did not cause any side effects, with the exception of some skin effects, such as redness on the chest, which was carried out incorrectly, but which subsequently went away,” the doctor wants to assure. We believe there are no consequences or loss of opportunity for delaying treatment of her abnormal breasts.” “On the other hand, yes, there is psychological trauma,” he adds.

In Tours in November, a patient was also given 25 sessions of radiation to the wrong breast. These incidents are not limited to breast cancer. In December, the Fleuriat hospital center in Bourg-en-Bresse announced an error in the treatment of a patient with oropharyngeal cancer. Instead of the diseased area, the healthy side was treated.

Severity Level 2

The ASN classified these incidents as severity level 2 due to overdose and the risk of adverse effects to patients on the ASN-SFRO scale, graded from 0 to 7.

The administrative authority reminds that radiation therapy is a treatment method that uses ionizing radiation generated by a particle accelerator to destroy cancer cells. The beams are applied to the treated area in several sessions over several days.

The centers conduct an analysis of the circumstances of the incident and send a report to them. In two recent cases in Dijon and Montpellier, an error was made in the preparation of treatment, and subsequent stages of the treatment process did not allow it to be corrected, ASN points out.

“Corrective actions identified by the center should also be implemented at the earliest and their effectiveness should be verified by the institution. They will also be subject to inspection by the ASN as part of their control activities,” the administrative body clarifies.

“ASN notes an increase in these types of errors and reiterates to radiation therapists the need to evaluate the reliability of the safety barriers installed to protect against lateral errors,” the agency concludes, citing the published brochure. on the topic in 2014. The document was written after the announcement of six errors that occurred in 2013.