Radiotherapy for head and neck cancer
Radiotherapy for head and neck cancers is usually given in combination with chemotherapy. This is known as chemoradiation. This may be used instead of or after surgery.
Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells. It’s an important treatment for head and neck cancers. Radiotherapy can be used on its own but is often given in combination with chemotherapy (called chemoradiation).
Radiotherapy for early cancers
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Radiotherapy can be used on its own to treat cancers that are small and haven’t spread. It’s often used for cancers in harder-to-reach areas, such as the back of the mouth or throat. Radiotherapy may also be used when surgery could seriously affect important functions such as speech and swallowing.
Radiotherapy for locally advanced cancers
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If a cancer in the head or neck is larger, or is affecting other tissues nearby (locally advanced cancer), radiotherapy is usually combined with other treatments.
Radiotherapy may be given:
after surgery (with or without chemotherapy) to destroy any remaining cancer and reduce the risk of cancer coming back
in combination with chemotherapy (chemoradiation), without surgery
in combination with the targeted therapy drug cetuximab
to reduce symptoms caused by a tumour (palliative radiotherapy).
Radiotherapy after surgery (adjuvant radiotherapy)
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If you have surgery for advanced cancer, you’ll usually be given radiotherapy afterwards. This is to reduce the risk of the cancer coming back and is called adjuvant radiotherapy. Sometimes both chemotherapy and radiotherapy are given together after surgery. This called adjuvant chemoradiation.
If you need adjuvant treatment your specialist team will assess whether radiotherapy or chemoradiation is best for your situation.
Chemoradiation is often the main treatment for advanced head and neck cancers. It may be used:
to treat cancers that can’t be removed with an operation
to treat cancers in harder-to-reach areas such as the nasopharynx or throat
when surgery could cause unacceptable changes to speech or swallowing.
Radiotherapy and cetuximab
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Combining chemotherapy and radiotherapy is a very effective treatment for head and neck cancer but it can also cause severe side effects. Some people can’t have chemoradiation because they aren’t well enough to cope with these side effects or they have other health problems that make chemotherapy too risky. Instead, they may be given radiotherapy in combination with a targeted therapy drug called cetuximab.
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Sometimes it’s not possible to cure a cancer and the main aim of treatment is to relieve symptoms. This is called palliative treatment.
Palliative radiotherapy may be used to stop bleeding from a tumour or to shrink a tumour that is causing swallowing or breathing difficulties. It can also relieve symptoms if a head and neck cancer has spread to other parts of the body.
How radiotherapy is given
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Radiotherapy can be given in two ways:
From outside the body as external beam radiotherapy. A beam of x-rays or electrons is directed at the cancer from a large machine called a linear accelerator. This is the most common way of giving radiotherapy to the head and neck area.
By putting a radioactive source into the tumour and leaving it there for a few days. This is known as internal radiotherapy, interstitial radiotherapy or brachytherapy.
To make sure that your radiotherapy is as effective as possible, it has to be carefully planned. Planning ensures the radiotherapy rays are aimed precisely at the cancer and cause the least possible damage to the surrounding healthy tissues. The treatment is planned by a specialist doctor known as a clinical oncologist. Planning is important and may take a few visits.
On your first visit to the radiotherapy department, you’ll have a CT scan taken of the area to be treated. During the same visit, radiographers (experts in giving radiotherapy) will take measurements to tailor the treatment to you. This session will usually take about 45-60 minutes.
Some people also have an MRI scan as part of their radiotherapy planning.
The radiographer’s measurements and the information from the scans are fed into the radiotherapy planning computer so that your doctors can plan your treatment precisely.
Occasionally, marks may be drawn on your skin. These help the radiographer to position you accurately before each treatment. The marks must stay visible throughout your treatment, but they can be washed off once your course of treatment is over.
It’s important that you’re able to lie still, in exactly the same position, for each treatment. To help you do this, you’ll wear a see-through plastic mask (sometimes called an immobilisation shell) for each session of radiotherapy.
The mask holds your head and neck as still as possible. It’s designed so that you can see and breathe normally while wearing it. You’ll have it on for up to about 15 minutes at a time. Most people soon get used to it.
Your mask will be made on one of your first visits to the radiotherapy department. The radiographer or the mask room technician will explain the whole process to you before starting.
We have more information about how radiotherapy masks are made.
Very occasionally, radiotherapy to the mouth or throat can cause swelling in tissues around the airways, which can make breathing difficult. If this is likely to happen, your doctors will arrange for you to have a small opening made in your windpipe before you have radiotherapy. The opening is called a tracheostomy or stoma and will let you breathe comfortably. A tracheostomy is usually temporary.
Before each treatment session, the radiographer will position you on the treatment couch and carefully fit your mask.
The treatment only takes a few minutes. During this time, you will be left alone in the room, but the radiographer will watch you from the next room. If you need assistance, you can raise your arm and the radiographers will return to the room.
External radiotherapy doesn’t make you radioactive, and it’s perfectly safe for you to be with other people, including children, throughout your treatment.
Side effects of radiotherapy
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Radiotherapy to the head and neck can cause temporary side effects such as a sore mouth or throat and difficulty swallowing. Side effects can be mild or more troublesome, depending on the dose of radiotherapy and the length of your treatment.
They are usually more severe if you have radiotherapy combined with chemotherapy.
Side effects usually begin to develop after about two weeks of radiotherapy. They may continue to get worse for 7-10 days after treatment ends before gradually improving. Most people find that side effects have noticeably improved 6-8 weeks after radiotherapy has ended.
Sometimes radiotherapy can cause long-lasting side effects or new side effects that develop months or even years later. These are called long-term or late effects. Two of the most common late effects are a dry mouth and an increased risk of tooth decay. Therefore it’s very important to follow a regular mouth care routine during and after radiotherapy.
Your specialist can tell you whether your treatment may cause any late effects. You’ll also be told about things you can do to help reduce your risk of having problems.
What you can do to help reduce side effects
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Smoking during radiotherapy is likely to make your side effects worse, and it reduces the effect of radiotherapy on the cancer. So, if you smoke, stopping will help your recovery. You can get information and support to help you stop. We more information about how to stop smoking.
Cut down on alcohol
Alcohol, especially spirits, will irritate the areas affected by your treatment. So, it’s best not to drink alcohol or use mouthwashes containing alcohol during radiotherapy.
Look after your mouth
It’s very important to look after your mouth during and after radiotherapy. Keeping your mouth as clean as possible can help protect your teeth, encourage tissue healing and reduce the risk of problems in the future.
Eating can be a struggle during treatment, but it’s important to get the nutrition you need. This will help your tissues to heal, increase your strength and can also reduce your risk of getting some long-term effects of radiotherapy.
Tell your specialist nurse or radiographer or ask to see a dietitian if you’re finding it difficult to eat. There are lots of things that can be done to help make sure you get the nutrition you need. If swallowing is a problem, a speech and language therapist can give you advice and support. We have more information about how to cope with eating problems.
Radiotherapy to the head and neck often reduces the amount of saliva you can make. Saliva washes your teeth and protects them from decay. So, during and after radiotherapy, you’ll be much more prone to tooth decay. Following a regular mouth care routine is very important, or your teeth could rot very quickly.
You’ll need to see your dentist and oral hygienist regularly. Going for regular check-ups means that if you develop any mouth problems, they can be picked up early when they’re easier to treat.
You’ll be shown how to keep your mouth and teeth clean, and given fluoride gel to apply to your teeth every day. It’s really important to use the gel as it will help to protect and strengthen your teeth.
You’ll be prescribed painkillers to take regularly. It’s important to tell your cancer specialist if you’re mouth is still sore as you may need stronger painkillers or have an infection in your mouth that needs treatment.
If your dentures are uncomfortable, try leaving them out overnight.
If your mouth or throat is sore avoid smoking, drinking spirits and eating spicy, sour, acidic or salty foods. You can be prescribed mouthwashes and protective gels that coat the lining of the mouth.
Choose soft foods and moisten them with sauces and gravies, butter or custard, as this can make eating easier.
If you’re having problems with swallowing, ask to see a speech and language therapist. They can assess your swallowing and give helpful advice.
If you find eating difficult, try high-calorie drinks such as Complan® and Build up®. They are available on prescription or you can buy them from a pharmacy or some larger supermarkets. You should discuss any eating problems with the dietitian or specialist nurse at the hospital. They may prescribe supplement drinks, such as Ensure® or Fortisip®, which are complete meals in liquid form.
Sometimes eating and drinking becomes too uncomfortable and some people need to be fed through a gastrostomy or nasogastric tube for a time.
Once your course of radiotherapy has finished, your mouth will gradually heal and most people get back to eating normally after a few weeks.
Here are some tips for looking after your mouth and teeth:
Brush your teeth (and dentures) with a small, soft toothbrush after each meal.
Use fluoride toothpaste and fluoride gel or mouthwash daily, as prescribed by your dentist.
Use dental floss or tape daily to clean in between your teeth (but check with your specialist doctor or nurse if you’re having chemotherapy or radiotherapy).
Rinse your mouth with a non-alcohol based mouthwash.
Inspect your mouth daily for signs of infection (ask your dentist or specialist nurse what to look for).
Take sips of water and rinse your mouth regularly during the day to keep your mouth moist.
Avoid sugary foods or sugar in drinks in between meals.
Avoid acidic drinks, such as fizzy drinks and fruit juices.
Do jaw exercises as advised by your specialist to prevent jaw stiffness.
Visit your dentist and hygienist every 3-6 months.
Managing side effects during radiotherapy
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Sore and sensitive skin
The skin over your face and neck will gradually redden or darken and may feel sore and itchy (like sunburn). This starts after about two weeks of treatment and lasts for up to about four weeks after radiotherapy has finished.
The radiotherapy team will give you advice on how to look after your skin. It’s very important to use only the soaps, creams and lotions that they recommend, as chemicals in some products can make the skin more sensitive to radiation.
Loose cotton clothing is less likely to irritate sore skin. It’s also best to avoid clothes with stiff or tight collars.
The skin in the area being treated will be more sensitive to the sun during and after radiotherapy (especially in the first year). Covering up with a sun hat and a soft cotton or silk scarf around your neck will help protect your skin from the sun.
But, don’t use sun protection creams on your head and neck while you’re having radiotherapy. The radiotherapy team can give you advice about when and how to use sun protection cream after your treatment.
Sore mouth and throat
Your mouth and throat are likely to become sore after a couple of weeks of treatment and you may develop mouth ulcers. Following a mouth care routine to keep your mouth clean will help to prevent problems.
Loss of taste
If you have radiotherapy to your mouth, it will affect your sense of taste. Some people lose their sense of taste completely or find that everything tastes the same (usually quite metallic or salty). Although your sense of taste should recover, it may take many months for this to happen.
A hoarse voice
You may notice your voice becomes hoarse during treatment. If this happens, don’t strain it. Try to rest your voice and avoid smoky atmospheres. A speech and language therapist can give you more advice on what to do if your voice becomes hoarse. Your voice will usually recover after a few weeks.
Radiotherapy can affect the salivary glands, so you may notice that you don’t make as much saliva as before. Your mouth and throat may become dry. This can make eating and speaking more difficult.
Sipping fluids regularly helps reduce the dry feeling. Soft, moist foods with gravies and sauces will be easier to eat than dry or chewy foods.
You may be prescribed artificial saliva to help your mouth feel more comfortable. It comes in different forms such as sprays, gels and lozenges. You may have to try different types to find one that suits you.
Some people find that using a humidifier in their home helps as it makes the atmosphere less dry.
Your lips can also feel dry and chapped. You can keep your lips comfortable by using a lip balm regularly. But you should avoid products that are coloured, perfumed or flavoured during radiotherapy.
After a few months you may begin to make saliva again, but it may not be as much as before. Sometimes the salivary glands don’t recover, which leaves the mouth permanently dry.
Thick, sticky saliva (mucus)
Radiotherapy can change the consistency of your saliva. It may become thicker, stringy and sticky, like mucus. The mucus doesn’t flow as well as normal saliva so it may build up in your mouth and throat.
You may feel the need to spit frequently to get rid of the mucus build-up, so it’s a good idea to keep tissues handy. Rinsing your mouth regularly can help to cut through the mucus. You can make a mouth rinse with half a teaspoon of salt and half a teaspoon of baking soda mixed into a litre of water. Alternatively, your specialist nurse can give you advice on the type of mouth rinse that’s suitable for you.
Sometimes mucus build-up can cause coughing, especially at night. Your nurse or doctor may prescribe nebulisers (a liquid that is mixed with air to make a mist or fine spray) to help to loosen the mucus. If your sleep is disturbed by coughing, using a nebuliser before bed may help.
Changes in your saliva usually get better within about eight weeks of radiotherapy ending but sometimes continue for several months or longer. If the mucus continues, there are medicines that can be prescribed to reduce the amount you make. Tell your cancer specialist or nurse if you’re having difficulties.
This is usually caused by changes to your saliva and can be reduced by regular mouth care. It may also be caused by an infection in your mouth, which is common during radiotherapy treatment. If you have an infection, it can be treated with antibiotic or antifungal medicine.
Feeling sick (nausea)
Sickness is more likely to affect people who have combined chemotherapy and radiotherapy treatment. If it’s a problem, your doctor can prescribe anti-sickness medicines (anti-emetics).
During treatment, you’ll need to rest more than usual, especially if you have to travel a long way for treatment each day. But it’s good to do some gentle activity, such as taking a short walk, if you feel able to. Once your treatment is over, gradually increase your activity. This will help build up your energy levels. We have more information about coping with fatigue.
Possible late (long-term) effects of radiotherapy
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Modern ways of planning and giving radiotherapy are designed to limit the chances of late side effects as much as possible. But some people do have long-term effects after head and neck radiotherapy.
If you’re concerned about the risk of developing particular side effects, you should speak to your cancer doctor or specialist nurse.
Here we discuss some of the long-term effects that can occur, but you won’t necessarily experience them. We also give suggestions on what you can do to manage these effects and to help reduce the risk of more serious problems developing. Your cancer team can give you more information and support.
Dry mouth and tooth decay
After treatment, the salivary glands may gradually begin to make saliva again. But your mouth may still be drier than it was before treatment and some people will have a dry mouth permanently.
Saliva protects our teeth against decay. If you have less or no saliva in your mouth, you have a much higher risk of tooth decay. This means it’s really important to protect your teeth by following a mouth care routine and seeing an oral hygienist and dentist regularly.
Difficulty opening your mouth due to a stiff jaw (trismus)
After radiotherapy to the head and neck, the muscles that open and close your mouth can become stiff. You’ll be shown gentle mouth-opening exercises that can help to prevent or relieve problems. There are also specialist aids available to help you exercise your jaw.
Your doctor, specialist dentist, or speech and language therapist can give you advice about exercises and the possible benefits of using an exercise aid. Organisations such as Saving Faces can give you help and support.
The jawbone can sometimes be affected by radiotherapy. This is called osteoradionecrosis. Your cancer specialist can tell you if this may be a risk for you.
The bone is a living tissue and is constantly renewing itself. After some types of radiotherapy to the head and neck, the jawbone can’t renew itself as well as before. This can sometimes lead to some of the bone tissue dying, called osteoradionecrosis. This may cause pain, numbness or a feeling of heaviness in the jaw, and sometimes swelling around the gum or loose teeth.
Most people will never develop osteoradionecrosis but certain things can increase the risk. These include:
infection in the jawbone
having a tooth removed
surgery to the jaw
Because infection or having a tooth removed after radiotherapy can increase the risk of osteoradionecrosis, it’s important to look after your mouth and teeth to try to prevent problems.
If you need to have one or more teeth taken out after radiotherapy, it’s important to see a specialist oral and maxillofacial surgeon. They will plan your treatment to reduce the risk of bone problems developing.
Changes to your thyroid gland
The thyroid gland is in the front of the neck. It produces hormones that help the body to function at its normal rate.
If the thyroid is exposed to radiation during radiotherapy, it may become underactive months or years later. This is called hypothyroidism. The symptoms of hypothyroidism can include feeling tired and lethargic, gaining weight and having dry skin and hair.
If your doctor thinks you may be at risk of developing an underactive thyroid because of radiotherapy, you’ll have regular blood tests to check how your thyroid is working. Treatment for an underactive thyroid gland is very effective and involves taking thyroxine tablets every day.
Changes in your hearing
If you have radiotherapy for nasopharyngeal cancer, it may affect your hearing. The chances of this may be higher if you’re having radiotherapy at the same time as some chemotherapy drugs such as cisplatin, as this drug can affect hearing too.
Hearing changes may be temporary and recover after treatment. However, sometimes long-term hearing changes develop about 6-12 months after treatment