It’s a medical error which places the regional university hospital center of Tours (Indre-et-Loire) in embarrassment. This Wednesday, CHRU management held a press briefing to explain why one of their patients, suffering from breast cancer, had been irradiated in the wrong breast, which was healthy, for 25 sessions.
“It was a serious error that marked the CHRU teams and our first reflex was to support the patient,” recognized Floriane Rivière, the general director of the CHRU, to France 3. She promises that new measures must prevent this type of incident from happening again. “We have strengthened our protocols to guarantee optimal quality of care,” assures the director.
“We add a control step and we will re-interview the patient at the time of their first session and not just at the initial scan stage. These are the two barriers considered robust by the nuclear safety agency and which we have already put in place,” explains Isabelle Barillot, radiotherapist oncologist, to our colleagues.
The facts date back to the first half of 2023. A woman is treated by the oncology and radiotherapy department for breast cancer. She then begins her treatment which consists of sending ionizing radiation generated by a particle accelerator to destroy any residual cancer cells after surgery.
The second case of reversal in a few months
Except that after the 25th of the 28 scheduled sessions, the medical team realized a problem due to redness on the wrong breast. “A laterality error (right-left inversion) occurred during treatment preparation, resulting in the contouring of the left breast in place of the right breast as the area to be treated,” indicates the press release from the nuclear safety agency (ASN) who was notified at the end of June. The error would therefore have been made before the start of the treatment.
According to the ASN, “one of the factors contributing to this laterality error could be linked to the presence of discordant information in the report of the initial medical consultation”. Taking into account “overdose of the wrongly treated region and the risk of side effects, the ASN classifies this event as level 2, on a scale graduated from 0 to 7 in increasing order of severity”. Between two and five incidents classified as 2 have taken place each year since 2011.
The patient was informed of the error and its potential consequences. Olivier Le Floch, former head of the radiotherapy department at Tours hospital, assures France 3 “that there are immediate consequences such as erythema, sunburn on the breast. In the long term, fibrosis can set in after a few years, but there should be no major consequences.” Still according to the doctor, a new treatment program was offered to her for the affected breast and she is still being followed by the CHRU.
She was able to receive this good treatment, one month after the error was discovered, reports West France. The ASN which notes that this is the second time (in a few months according to France 3) that this type of inversion has occurred at the CHRU. With its new protocol, the hospital now intends to prevent these errors from recurring, thanks to cross-checks throughout the process. As a reminder, breast cancer, which affects one in eight women, is the most common and deadliest.