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Spencer Day
DOS 516-501: Fundamentals of Radiation Safety
Safety in Radiation Oncology

For newly diagnosed cancer patients, not only can the diagnoses be frightening, but the
course of treatment can be daunting as well. About half of cancer patients undergo radiation
therapy. Radiotherapy is also included in 40 percent of curative cancer treatments.1 Patients
expect safety to be a top priority, and radiation oncology (along with all medical fields)
prioritizes safety. However, radiation in particular appears to alarm the public. Several articles
over the years, including the 2010 New York Times article “The Radiation Boom: Radiation
Offers New Cures, and Ways to Do Harm” have thrust radiotherapy and safety into the public
spotlight.2 These articles and incidents did not go unnoticed by the radiation oncology
community, which has taken the opportunity to learn and improve radiotherapy safety.

In response to public distress over radiation treatments, a national meeting in the summer
of 2010 was held, sponsored by the American Association of Physicists in Medicine (AAPM)
and the American Society of Radiation Oncology (ASTRO). Participants from all positions
within radiation oncology field identified common sources of error in radiation therapy.
Advancement of computer technology in treatment delivery such as intensity- modulated
radiation therapy (IMRT) has led to therapists having less direct control and little instant
verification of treatment progress. Poor control area ergonomics could have caused delayed or
incorrect machine inputs, numerous outside distractions, and insufficient warning signals.
Workplace culture may also deter therapists from questioning doctor or physician orders.
Participants also concluded that errors cannot be eliminated due to the overall complexity of
radiation oncology, software or hardware failures, and presence of human decisions needed
throughout treatment.2

Errors will inevitably occur since mistakes are inherent of human nature. These errors can
be minimized, although errors must first be identified and understood to fix them. A study by
Lawrence Marks MD3 elaborates on the sources for human errors. One major source is
increasing complexity of workflows. Radiation oncology benefits from the advancement of
computer technology, but this also introduces more actions from the radiation oncology team like
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patient quality assurance (QA), image segmentation, and multi-leaf collimator maintenance to
name a few. This leads to more time constraints and dependence on the actions of other
members. With more interdependent actions, likelihood for error increases. Time expectation is a
source for error as well. More complex treatments like IMRT or stereotactic body radiation
therapy (SBRT) require more time for dosimetry to plan and it should be expected that advanced
technology may have more down time (maintenance) as well. Thus “pushing” through planning
or treatments leaves less time for double checks and critical thinking. Advanced technology has
also led to final QA checks, like light field and verification films being less useful. In decades
past where 2D and 3D treatment was prevalent, light fields gave a good estimate of the treated
area. Portal films like double exposures also gave a beam’s eye view of beam alignment and
treatment fields. While image-guided radiation therapy has more utility, with IMRT it is more
challenging to assure the treatment volume is properly aligned in all dimensions.3

Within radiation oncology there is a hierarchy of workers and a sequence leading to

treatment that catches errors yet mistakes still slip though. James Reason exemplified mistakes in
an organization through the “Swiss Cheese Model”. This model is a stack of swiss cheese slices
where each slice is a step in a process. For radiation oncology, the stack starts with consultation,
proceeding through steps like planning CT, treatment goals, plan optimization, plan approval,
and ends at treatment delivery. An error can be introduced anywhere within the “cheese slices”
and can percolate through holes in the stack representing lapses in judgment, miscommunication,
or no safety checks. Errors should be caught at the next slice, but if the mistake slips through the
last hole in treatment delivery, patient harm results.3 Reason’s model demonstrates that while
sequential steps help, they do not remedy all mistakes.

While it is evident that errors do occur in radiation oncology, there are numerous
solutions to ease patients’ concerns. Marks3 notes several improvements to be made in radiation
oncology. Proper scheduling and staffing can greatly improve safety. There needs to be enough
staff to handle the anticipated workload. The broader integration of IMRT, volumetric modulated
arc therapy (VMAT), and SBRT treatments requires more time for dosimetry to plan and physics
to check. Communication is vital between all members of a clinic. During treatment planning,
patient plans are transferred frequently between the dosimetrist, physician, and physicist. All
three must clearly convey their questions and directions. This could be helped by keeping the
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location of dosimetry and physician offices close. Communication is also key at time of delivery.
Therapists should feel comfortable asking for a timeout or clarifying a plan with the physician.
Standardization of workflow provides structure for therapists to follow while eliminating
wasteful steps and streamlining the process.3

During the national meeting in 2010 entitled “Safety in Radiation Therapy: A Call to
Action,” recommendations were listed on mitigating errors. Some of the key recommendations
included were simplifying machine controls, minimizing interruptions to therapists while
treating, better warning systems, requiring patient safety competencies for students, and
implementation of checklists. Participants agreed that treatment procedures must be fault
tolerant. The treatment process should be able to identify and remedy errors that occur.2

To counter radiotherapy incidents, ASTRO released a six-point action plan to improve

treatment safety. Points within the action plan reduce error by creating a national database for
reporting errors, enhancing accreditation programs, and creating tools that help patients
communicate with physicians among other improvements.2

Radiation oncology is a valuable asset in cancer care when implemented correctly. Past
incidents and the publication of these events in the national media have led the public to question
the safety of radiation therapy. While mistakes can never be eliminated, there is a persistent
effort to minimize errors, and consequently will ensure radiation therapy remains a safe,
effective cancer treatment.
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References:

1. Baskar R, Lee KA, Yeoh K. Cancer and radiation therapy: Current advances and future
directions. International Journal of Medial Sciences. 2012; 9(3): 193-199.
doi:10.7150/ijms.3635. Published February 27, 2012. Accessed October 26, 2020.
2. Hendee WR, Herman MG. Improving patient safety in radiation oncology. Medical
Physics. 2010; 38(1): 78-82. https://doi.org/10.1118/1.3522875. Published December 14,
2010. Accessed October 26, 2020.
3. Marks LB, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation
oncology. Practical Radiation Oncology. 2011; 1(1): 2-14.
https://doi.org/10.1016/j.prro.2010.10.001. Published April 2011. Accessed October 26,
2020.