Radiotherapy in Head and Neck Cancer

Radiation therapy or Radiotherapy uses high-energy radiations which targets cancer cells’ DNA and destroys their ability to multiply and grow and thereby helps in treating cancer.

A Radiation Oncologist is a specialized doctor in radiation oncology, who takes care of cancer patients undergoing radiation treatment. Radiation Oncologist plans, decides, and prescribes the treatment regimen and ensuring simultaneously, the accuracy of the treatment given, and monitors the patient’s progress.

Role of radiotherapy in head and neck cancer

Treatment of head and neck cancer in Hisar involves an interdisciplinary and integrated approach. Head and neck cancer radiation therapy or head and neck cancer radiotherapy can be either indicated alone or along with surgery. Head and neck cancers encompass various types of tumors originating from the head and neck region such as the upper digestive tract, paranasal sinuses, salivary and thyroid glands. The objective of radiotherapy is to control growth of the tumor simultaneously minimizing damage to the adjacent tissues and other organs.

Radiation therapy treatment in Hisar offers various advantages of convenience and time-saving to the patient that it is given on an outpatient basis which does not require hospital admission. Besides, it obviates the need for general anesthesia during surgery. However, the advantages, there are also radiation therapy-related side effects which cannot be ignored totally.

With the introduction of recent advanced technologies, like brachytherapy, intensity-modulated radiotherapy (IMRT), image-guided radiotherapy (IGRT), etc. radiotherapy has evolved greatly in the past decade. These modern radiotherapy techniques (e.g., IMRT head and neck cancer), allow the radiation delivery to be more precise simultaneously limiting the dose and avoiding harm to the surrounding normal tissues without compromising the target part. Proton therapy for head and neck cancer is an emerging and promising treatment modality, because of the potential to improve organ sparing and/or safely escalate doses of radiation delivered.

Conditions where radiotherapy is used

Head and neck cancer radiation therapy depends on many factors such as the stage, type and location of cancer as well as other medical problems of the patient. For head and neck cancer radiation therapy can be used in a variety of settings:

• Definitive radiation therapy (with or without chemotherapy): Definitive radiation therapy means that the treatment of the cancer is radiation. It can be combined with chemotherapy, which is called definitive chemoradiation therapy.
• Adjuvant radiation therapy (with or without chemotherapy): Use of radiation therapy after surgical removal of all of the tumor. There are less chances of cancer recurrence this way because the radiation destroys the microscopic cancer cells missed during the surgical resection.
• Neoadjuvant radiation therapy (with or without chemotherapy): This strategy is used mainly in clinical trials or certain cases of advanced disease. The non-surgical treatment is given first followed by the surgery later which helps in observing the response, and if there is any cancer remaining, a surgeon can remove it.
• Palliation of symptoms: Palliation therapy is useful specially in advanced metastasized cases to various sites, or when other standard treatment measures have failed leaving no option even for surgery. Such cases can be managed by radiation to palliate the symptoms i.e., to prevent a major complication and make the patient feel better.

Types of radiation therapy delivery methods

There are various techniques to administer radiation therapy, external beam radiation therapy and brachytherapy being the common ones used for most head and neck cancers.

• Standard external beam radiation therapy: This therapy uses either x-rays or gamma rays. The current standard of care in delivering external beam radiation for head and neck cancer is to use intensity-modified radiation therapy (IMRT). The radiation oncologist administers the radiation in a controlled manner to give more amount to the cancerous tissue while ensuring minimal radiation to normal tissue. For IMRT radiotherapy for head and neck cancer, the patient is administered a contrast media through injection into the body followed by a CT scan which are analysed by a radiation oncologist and a team of scientists. This team of specialists then discusses and plans the treatment personalised for individual patient.
• Brachytherapy: Brachytherapy, in contrast to external beam radiation therapy, uses needles or catheters placed through your skin to the target area and implants tiny radioactive “seed” within or in proximity to the cancerous tissue to which beams of photons are shot through the skin. Brachytherapy for head and neck cancer offers advantages of delivering more radiation to the targeted tumor tissue, sparing the normal tissue. Also, it administers continuous radiation which is suited for slow-growing cancers. But for brachytherapy, there is one limitation that the tumor must be well defined because radiation cannot be delivered as effectively to poorly defined growths.
• Intra-operative radiation therapy (IORT): A type of external beam radiation therapy which gives a high dose of targeted therapy aiming a specific area at risk of harboring microscopic cancer cells after surgical removal of major tumor mass. IORT is used in few selected centers, mostly in patients with extensive cancer that has returned after previous radiation therapy, or less commonly in very locally advanced cancers that are at high risk of recurring despite maximal surgery and external beam radiation. The ultimate goal of IORT with salvage surgery is to give the best chance of curing recurrent cancer while lowering the risks of a major complication. Not standard care now-a-days. exact role of IORT for recurrent cancer in the Head and Neck is not yet determined.
• Neutron beam radiation therapy: Applicable particularly in large tumors with areas of low oxygen and in large slow-growing tumors. Use in head and neck cancers is still being explored.
• Proton beam radiation therapy: Proton beam radiation therapy uses protons (instead of photons) to kill cancer cells. The usage of protons (as opposed to X-rays or gamma rays in the photons of standard external beam radiation) allows more precise delivery of radiation than even standard X-ray-based external beam radiation with IMRT. With this technique, there is less damage to normal tissue and decrease in side effects. But this is an expensive technique therefore may take time to be used commonly for treatment of head and neck cancers.
• Radiosurgery: It delivers very tight beams of radiation from multiple different directions to focus on a specific target area. Mainly useful in the treatment of benign disease but for treatment of head and neck cancers.
• Radioactive iodine: Does not utilize external beam and is used to treat certain stages of well-differentiated thyroid cancer. Radioactive iodine is given as a drink or a capsule. Since only the thyroid cells pick-up radioactive iodine, the normal cells are spared in this manner.

Side effects of radiotherapy and tips to manage them

Head and neck radiation or head and neck cancer radiotherapy can have side effects due to the effects of radiation on the normal tissue. Let us know about some of the common radiation therapy side effects head and neck region or side effects of radiotherapy for head and neck cancer.

The incidence and extent of adverse effects depends on the total dose of radiation, duration, the involvement of parts of the head and neck and many other factors.

• Xerostomia (dry mouth): It is one of the most common head and neck cancer radiation long term side effects. It occurs when salivary glands are radiated or in the line of radiation.
  • Common problems due to dry mouth: Difficulty eating and speaking, increased risk of dental cavities and dental diseases, etc.
  • Ways to manage: Frequent drinking/sipping of water or other liquids such as coconut water, artificial saliva preparations, certain medications prescribed by your doctor used around the time of radiation can also help reduce the severity, an aerosol pump spray bottle filled with water.
• Osteoradionecrosis (ORN) (bone death):‘Osteo’ refers to bone and ‘radio-necrosis’ refers to death due to radiation.This occurs due to the exposure of bone to radiation through the skin.
  • Problems due to osteoradionecrosis: Severe pain, could be associated with chronic and persistent infections, trauma to bone can also sometimes result into ORN if there’s less blood supply.
  • Ways to manage: Prevention is the only way for ORN. Prefer to get your dental work done before radiation, dental extractions should be done three weeks or more before starting radiation treatment and specially by a dentist who is familiar with the treatment of ORN. Post-radiation you should take very good care oral hygiene, including brushing and fluoride treatments.
• Odynophagia (and mucositis): Odynophagia refers to pain while swallowing. It occurs because of the redness, swelling and irritation caused to the mouth and throat lining (mucositis) due to radiation.
  • Ways to manage: Rinsing and swallowing liquids to numb the pain, sometimes strong pain medication are required. If patient has difficulty eating or drinking for long time, a feeding tube is inserted by your doctor till the problem has resolved or reduced in intensity.
• Skin/Hair changes: Changes in skin and hair is one of the Head and neck cancer radiation side effects.
  • Problems patients face: Increased hair-fall specially in the region that receives radiation, slight color changes to the skin or mild swelling, skin changes such as bright red or dark color, dry, itchy, flaky skin or rashes on the skin.
  • Ways to manage: For skin problems – Keep your skin clean, moisturized and hydrated. Avoid using alcohol or alcohol pads on the skin in the treatment area. Avoid any kind of irritation to your skin such as scratching, makeup, perfume, or aftershave specially on the treatment area.

  For hair problems – Switch to nutritious and well-balanced diet. Losing some of the hair in the treatment area is usual after radiation but the hair grows back around 3 – 6 months after the treatment is over.

• Hypothyroidism: Side effects of radiation therapy for head and neck cancers also includes hypothyroidism since it is located immediately in front of the throat.

Problems it can cause – Damage to the thyroid gland due to radiation can lead to hypothyroidism.

Ways to manage – Routine check-up of thyroid function tests, keep a check on symptoms such as new-onset tiredness and weight gain. The doctor will usually prescribe a thyroid hormone substitute pill once a day.

• Pharyngoesophageal stenosis: This is an area of narrowing in the pharynx or esophagus.

Problems it causes – Difficulty eating, specially solid food, difficulty drinking if the PE segment is completely closed off.

Ways to manage – For drinking problems, a feeding tube placed directly into the stomach (gastric tube) aids feeding. Sometimes, placement of dilating catheters down the throat to stretch and open the narrowed segment or surgical removal of the blocked segment with flap reconstruction.

Points to remember if you’re undergoing head and neck cancer radiation therapy:

• Take good care of yourself before, during and after your treatment. Remember a few points:
• Side effects of radiotherapy are not long lasting and takes around 4 – 8 weeks to resolve after stopping your treatment.
• Keep a habit of regular medical and dental follow-ups with your doctor even if you don’t have any serious problems.
• For dental treatments, better consult a dentist with experience treating people with head and neck cancer radiotherapy.
• Maintain a good oral hygiene including regular brushing and flossing habits and use fluoride toothpaste recommended by your dentist.
• Switch to a healthy, well-balanced and nutritious diet.
• Avoid drinking alcohol and tobacco use.

Conditions when you must contact your radiation oncologist/nurse:

Please do not ignore any of the following symptoms and try to immediately reach out/contact your Radiation Oncologist or Nurse in case you have:

• Fever with temperature ≥ 100.4° F (38° C)
• Chills/ shivering
• Peeling -off, blistering, or weepy skin with pain
• Long-lasting and/or severe nausea or vomiting disturbing your routine
• eating or drinking for 24 hours
• Constipation not relieved by prescribed medication
• Pain not relieved by prescribed medication