Radiotherapy to the Head and Neck area

Radiotherapy to the Head and Neck area

Introduction 

This leaflet will explain possible side effects which may develop when receiving Radiotherapy to your head and neck area.

These effects are individual and will depend on the dose of radiotherapy you receive and the length of your treatment. Everyone reacts to Radiotherapy differently and not everybody will experience all the side effects mentioned. Most side effects are temporary and diminish with time. Acute (early) side effects may start at varying times during treatment and disappear in the weeks after treatment finishes. Late side effects may not occur for quite a long time after the treatment has finished. 

The Radiographers will explain your possible side effects in more detail and answer any questions you may have before you start treatment.

You may also be having chemotherapy treatment at the same time as your radiotherapy. Chemotherapy is the treatment of cancer with drugs. 

You will be given specific written information and consented separately for this.

You will have weekly blood tests while you are having radiotherapy treatment, this is so we can monitor some of the components in the blood and make sure they are within tolerance for treatment.

Diagram showing areas of the mouth, throat and neck

Acute (early) side effects 

These can occur whilst you are undergoing Radiotherapy and in the weeks immediately afterwards. They tend to be cumulative so may not occur in the first week.

Symptom	When will it occur?	How do I manage it?	How long will it last?
Red, dry sore and possibly broken skin   (will depend on area of  treatment but generally neck and face, you can check this with your treatment radiographer)	Redness- around week 2-3       Broken skin around week 4 onwards	Please discuss use of moisturising creams with your treatment team, they will be able to give you suggestions on which moisturising creams to use. Electric shave only.Avoid perfume, make up, talc and aftershave in treatment area. Dressings will be applied when skin is broken. After end of treatment you may need to organise these through your GP practice.  Avoid sun exposure to treatment area	Skin reactions will peak about 2 weeks after treatment finishes.   They will then heal gradually and any redness or darkening will get better over the next 8-12 weeks.
Sore mouth/throat/lips.   The inside of the mouth, tongue and throat may become red, sore and ulcerated. It may become uncomfortable to eat and speak and brush teeth. Sometimes it is possible to develop an infection known as thrush.	About week 3	Use regular mouthwash as prescribed, (Mucosamin or Gelclare.) Use pain relief regularly. Use a lip balm, please ask radiographers for suggestions. Clean your teeth with a fluoride toothpaste and soft tooth brush if possible. If brushing becomes too painful later in the treatment, please use a baby toothbrush and toothpaste.You may need medication if you have thrush, this will be prescribed by the hospital.	Slowly settles over 6-10 weeks after finishing treatment.

Symptom	When will it occur?	How do I manage it?	When will it get better?
Painful swallowing	About week 2-3	Avoid citrus/spicy foods. Use soft textured, wetter foods with plenty of sauces and gravy. Use regular painkillers. Regular weekly review with dietitian and Speech and Language (SLT) Use PEG feeding tube and supplement drinks which can be supplied via GP and hospital.	Effects of treatment remain the same for at least 2 weeks before gradually beginning to improve. You will be seen regularly by SLT and dietitian. Your swallow should then gradually improve over time.
Reflux	After the feeding tube fitting.	Using an anti-reflux medication prescribed by the hospital or GP daily.	Once the feeding tube has been removed.
Taste changes	Variable, can be from about 2 weeks onwards however some people may experience sooner.	Use of herbs, honey, sauces to flavour food or trying foods that you may never have had before. Although taste changes may reduce your appetite it is important to carry on trying to eat orally as this will help your swallow muscles.	This can improve over weeks or even months after treatment finishes.   There is a possibility it will continue for many years and in some cases poor taste may be permanent.

Symptom	When will it occur?	How do I manage it?	When will it get better?
Excess mucous /thick saliva production/ retching	About week 3	You may also use salt water mouthwash: 1 teaspoon of salt & 1 teaspoon of sodium bicarbonate in a tumbler of water. Swill this round your mouth then spit it out. Drink plenty of fluids Use a nebuliser, this will be supplied by hospital as/when required. It is a device you can take home with you and use as often as you wish to. It helps thin the thick secretions in your mouth and throat so you are able to spit them out easily. Best used at least four times a day.	8-12 weeks after finishing treatment.   Some patients may find they have changes to their saliva permanently, i.e. sticky or thicker.
Change in voice	Week 3-4	Weekly review with SLT Avoid straining to speak Will depend on location of tumour	8-12 weeks after finishing treatment Some changes may take months to settle and some may be permanent.
Restricted mouth opening-Trismus	Week 3-4	This depends where your cancer is. You will be given specific mouth exercises by your SLT.	This can be a long term problem.it is important to do regular mouth exercises to improve and keep your ability to open your mouth. These exercises may be a lifetime activity
Reflux	After your feeding tube is fitted.	Taking the anti-reflux medication prescribed daily.	Until feeding tube is in place.
Extreme tiredness-fatigue	Week 3 onwards	Gentle exercise when you feel able and some rest periods.Good nutritional intake; your dietitian will be able to help you with this.	8-12 weeks after finishing treatment. Try gentle daily exercise and gradually increase this over next few months, e.g. Walking, swimming.it may take up to 12 months to fully recover.

Symptom	When will it occur?	How do I manage it?	When will it get better?
Dry mouth	May occur as going through treatment or after treatment has finished.	Carrying a bottle of water and taking frequent sips. Using artificial saliva spray which will be supplied though the hospital. Providing mouth is not sore, sucking sugar free sweets or chewing sugar free gum. Avoid drinks which may further dry your mouth, like alcohol.	Some patients will have dryness for up to 2 years after finishing treatment. For others this may be a permanent change.
Hair loss in treatment area	Can be facial or hair at back or side of head but will not be whole head of hair.	Use electric shaver Can keep hair longer to hide area if possible.If treatment field below earlobes can	Hair may not grow back in the area that has been treated.   If it does it will usually regrow within
	Hair can stop growing from 3 weeks into treatment.	wash and dry hair normally. If includes part of scalp use gentle shampoo and dry naturally to avoid irritation.	3 months.
Lymphoedema   Facial and neck swelling	Sometimes can occur towards end of treatment.   Usually occurs 812 weeks after finishing treatment.	 Sometimes you may need a course of massage treatment, and you will be referred to a specialist lymphedema clinic/ nurse.	This usually gets better between 6-12 months after your treatment has finished. You may need to carry on doing self-massage for longer than 12 months.

General advice

Smoking

It is strongly recommended that you stop smoking completely whilst undergoing radiotherapy. Smoking can make treatment side effects more severe, the treatment harder to tolerate and less effective. For help to stop smoking call the National smoke free Helpline on 0300 123 1044 or contact the hospital’s stop smoking service: 0300 123 0619 or 01562 513225.

Alcohol

It is advised that you reduce the amount of alcohol that you drink. Spirits should be totally avoided during treatment to prevent increasing the side effects, though beer and wine may be drunk in moderation. If you are concerned that you may suffer from alcohol withdrawal, then please speak to your Consultant/GP before starting radiotherapy treatment.

Specialist counselling is also available for patients and their families having treatment for Head and Neck cancers.  Please ask a member of your treatment team about referral for counselling.

Effects on your mouth and throat

If your mouth is included in the treatment area you may find-:

• The saliva will start to become thick and later the mouth will become dry.
• Food may become tasteless.
• Swallowing may be difficult.
• You develop an irritating cough, especially when you lie down. It may be helped by frequent sips of fluid (carry a bottle of water around with you). 
• If your voice box is in the treated area, it is likely to become hoarse as treatment progresses. If this happens rest your voice as much as possible. 

Management

During radiotherapy it is very important to: –

• Brush teeth /gums /tongue using a small soft toothbrush (and fluoride toothpaste if tolerated) at least twice daily.
• Do not use a commercial mouthwash as they may contain alcohol which will dry and irritate your mouth.
• You may be prescribed medication to keep your mouth clean and help prevent infections.  
• Mucosamin mouthwash will be supplied to you from the department.
• Steam inhalation may help with thickened saliva and an irritating cough. 
• Dentures should be removed and cleaned after each meal, at least 2x daily.
• Dentures should be left out at night and soaked in an appropriate cleanser for up to 20 minutes. Afterwards they should be kept dry 

Remember – If you are not wearing your dentures you must keep them in water to keep them in good condition.

Your diet

You will be given help and advice during treatment by the Head and Neck Team, which includes a Dietician and a Speech and Language therapist. An appointment will be scheduled weekly with the team alongside your daily radiotherapy treatment. 

You may find that it becomes difficult to swallow as your throat becomes sore.  It is important that you continue to swallow during treatment and the recovery period, even if it is only sips of water. In some circumstances you may be advised not to take anything by mouth and be dependent on tube feeding.  Your team will discuss this with you.

Avoiding weight loss will also help to keep your mask fitted correctly.

It is also possible that you may feel sick during treatment. If this happens let your team know and anti-sickness medication can be prescribed for you. 

Management

Some basic advice to follow includes:

• Avoid food that is very spicy, salty or acidic tasting as it can irritate your mouth.  Eat little and often to stimulate your appetite 
• Avoid hot or cold temperatures of food and drink.
• Modifying the texture of your food by adding extra sauce, mashing or blending.
• Try to eat food that is high in calories e.g. full fat milk or yoghurts, add grated cheese to mash potatoes, use cream in soups  Supplement drinks may be prescribed.
• Sometimes it maybe that you will need to be fed through a tube, if required this will be explained to you by a member of the team.

Late effects of treatment

Late effects occur months or years after treatment has finished:

• Your dry mouth may be permanent, but your consultant or a member of the team will discuss this with you.
• A change in taste may take some time to return to normal, occasionally it may never completely return.
• The sore mouth and skin will recover, but the effects of radiotherapy continue working after the treatment has stopped so your skin reaction may get worse in the week after treatment and it may take 4 to 6 weeks to heal.
• If you have problems with swallowing, the Speech and Language Therapist may be able to help. 
• If your mouth remains dry, there is an increased risk of deterioration of your teeth. It is important that you see your dentist and hygienist regularly. Brushing with fluoride toothpaste will help and you may need a fluoride mouthwash. Your dentist will advise you about this. It can help to eat foods with plenty of gravy or sauce.
• On occasion the jaw bone can be damaged by radiation, particularly if teeth need to be removed in the future. Please discuss this with your consultant or a member of the team.
• There is a late toxicity risk of developing hypothyroidism or very rarely a secondary cancer.

If you have any concerns about any of these effects, please discuss with your Consultant. 

Follow–up clinic appointments

After finishing treatment your Head and Neck Team will continue to support you. 

Joint clinics by the head and neck team will be offered one week after finishing treatment and then weekly until symptoms are resolved.

You will also receive an appointment to see your consultant in the out-patient department between 4 and 6 weeks later. These appointments are to check your progress and may continue for several years. If you haven’t received notification of this within three weeks of completing treatment, please telephone radiotherapy reception on 01905 761400

Treatment contacts:

Head and Neck Radiographer: 01905 761 400

Head and Neck CNS team: 01905 761 440

Head and Neck Dietetics team: 01905 760 136

Head and Neck SALT team: 01905 760 475

Support Groups:

The Swallows, Head and neck support group, meet 2^nd Wednesday every month.  Visit at theswallows.org.uk

Email [email protected]

Contact details Chris Byrne 07771937821

John Anthony Scott 07583619448

01843 833724 or www.lets–face–it.org.uk

National Association of Laryngectomee Clubs, NALC:

020 7730 8585 or www.laryngectomy.org.uk

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience

We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback

Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.  

Patient Advice and Liaison Service (PALS)

If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences. 

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure. 

How to contact PALS:

 Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

 Opening times:

 The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be    aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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