Radiotherapy accident linked to failure to take account of a previous course of radiotherapy, resulting in a major overdose during a second course of external radiotherapy.
Press release
On 20 June 2024, the French Nuclear Safety Authority (ASN) was informed of a significant radiation protection event that occurred during the external radiotherapy treatment of a patient with recurrent pelvic cancer at the Oncorad Garonne oncology-radiotherapy centre in Toulouse.
External radiotherapy is a treatment technique that uses ionising radiation generated by a particle accelerator to destroy cancer cells. The ionising radiation is administered to the area to be treated in one or more fractions, delivered over one or more days.
The treatment, delivered during the summer of 2023, did not take into account a previous external radiotherapy treatment carried out several years earlier on the same anatomical region. A full course of treatment (38 sessions of 2 grays) was therefore given in 2023, resulting in over-irradiation of the organs at risk, given the first course of radiotherapy.
The occurrence of major lesions requiring surgical management several months after the end of treatment enabled over-irradiation to be identified.
Given the appearance of serious late effects linked to the patient's irradiation, with major impairment of quality of life, the ASN classifies this event as level 4, qualified as an accident, on the ASN-SFRO scale of radiotherapy events, graded from 0 to 7 in ascending order of seriousness.
Following this event, the radiotherapy centre initiated an in-depth analysis of the circumstances and causes of the accident by the multidisciplinary feedback committee, which will identify the defence barriers that did not work and the corrective actions to be implemented to reduce the risk of a similar event occurring.
The precise analysis of the event, the improvement actions identified and their effective implementation will be verified as part of the ASN's inspections of the radiotherapy department of the Oncorad Garonne group.
The ASN points out that the June 2020 bulletin on patient safety, "Radiotherapy history", highlights the major clinical issues involved in the management of patients who receive several courses of radiotherapy during their lives, and sets out avenues for progress. Identifying this risk in the a priori analysis, putting in place safety barriers and assessing them regularly, compiling and archiving complete medical and technical records, and questioning the patient are all essential points of attention.
Date of last update : 17/07/2024