Welcome to the world of the  ‘Wherethehellarewe’ tribe, so called because prolonged bouts/sessions of either RT/CT can leave you wondering exactly where you are with all that’s going on! Starting on the trail of chemo/radfiotherapy is the start of the death of those horrible little cancerous cells and if it doesn’t quite obliterate them then surgery is always the final option. For some people it is very difficult to understand that cures/preventatives come with risks attached, but, whatever they may be, the aim is to return the human body (your body) to the fighting fit machine it was before any of this nasty old cancer ever appeared.

Side effects of radiation treatment for head and neck cancer

      The most often used, to treat head and neck cancer, is Radiotherapy and it can be used as the only treatment. However it is often used after a stint on the Chemotherapy trail  and after a surgical procedure to ensure that there are no cancerous cells left to dide/mutate etc. The aim of radiotherapy is to kill cancer cells and because these cells divide and grow at a faster rate than normal cells they are more likely to be destroyed. A slight problem is that healthy cells may well suffer under the onslught of radiotheray but they will recover quite quickly.     

     The ‘downside’ with radiotherapy is that there are causes and long term side effects; ie,  damaged blood vessels (that nourish muscles), nerves, and bones that can result in a progressive condition called “radiation fibrosis syndrome“, which causes a variety of complications affecting nerve, muscles, and bones. Wierdly, some side effects (e.g; nausea, mucositis) are generally more pronounced in those who receive radiotherapy & chemotherapy.

Radiotherapy can be administered in several ways:

     1. Organ Care: The beams of radiotherapy are aimed at the tumor site after very precise measurements by your consultant.  It is used in an attempt to cure the disease without surgically removing the larynx. However, as in my case, this is not always an option because of the size and location of the tumor and the ultimate recourse is to proceed directly to surgery.
2. Palliative treatment: Radiation is given in an attempt to prolong your life when the tumor is too large and/or inoperable and cure is highly unlikely. Note here that some people choose NOT to continue and that is their ‘freedom of choice‘ to do so.
3. Radiation after surgery: Radiation is given after surgery to destroy any local residual cancer cells that may spread to other organs such as the lungs, liver, or brain.
4. Reirradiation for recurrent cancer: Radiation is administered for any repeat appearances of head and neck cancers.
nb:… all the above involve ‘The Mask’ a subject we will brooch later.

Different types of Radiotherapy:

     Macmillan have a marvellous site for full explanations of what happens etc. Just be aware that different tumours (size/shape etc) may require varying degress/amounts of radiotherapy   

Methods of radiation include:

1… Brachytherapy … (is a form of radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment. Brachytherapy is commonly used as an effective treatment for cervical, prostate, breast, and skin cancer and can also be used to treat tumours in many other body sites).

2… intra-operative radiation therapy … ( [sometimes abbreviated IORT] is a relatively new way to give radiation therapy. During surgery to remove breast cancer, radiation is given as a single dose directly to the area where the cancer used to be).

3… Neutron beam radiation therapy … ( is a highly effective form of radiation therapy. Long-term experience with treating cancer has shown that certain tumor types (pathologies) are very difficult to kill using conventional radiation therapy. These pathologies are classified as being “radioresistant”).

4… Proton beam radiation therapy … ( ‘x’ marks the spot ie,this is a very precise radiation).

5… Radiosurgery … ( is surgery using radiation, that is, the destruction of precisely selected areas of tissue using ionizing radiation rather than excision with a blade. Like other forms of radiation therapy (also called radiotherapy), it is usually used to treat cancer).

Now for the dreaded mask!

     Now this contraption is enough to make you think of ‘tortures of old’ where, in medieval days, such instruments as the Iron Maiden, The Rack & The Thumbscrew (to mention but a few) and believe you me it is not for the faint hearted. Having given you all a severe case of the ‘collywobbles’ I can assure you that I suffer claustrophobia not at all well but I mastered the art of complete relaxation 32 out of 33 visits to the table. The one day I struggled, the girls (nurses) quickly released me from the table and gave me a few minutes to ‘get with it again’.

     If you look carefully you will see that there are several tightening screws along the base of this creation/mask, which is made of a soft plastic, warmed and moulded around your head & face. Once it has dried/cooled it retains its shape and when moulding takes place the nurses place a 2 mm ‘board under your head so that, although screwed to the table, the mask does not completely imobilise you when radiotherapy takes place! The 2mm spacer is removed and you lay absolutely flat thus giving a 2mm clearance above your nose/forehead (which is very welcomed indeed). Refer to previous statement of ‘claustrophobic’ tendencies and you can relax knowing that there is a modicum of movement available.

     If you look even more carefully you will see three (3) crosses (X) marked on the mask and these are the places/spots where your oncologist has determined that the rays should be aimed at to eradicate your cancer. Some people may only have a single target, some may have four. Whatever it is, try to relax and just think about your last/next holiday or some other pleasurable memories etc.

Risk of cancer in smokers:-

is further enhanced by alcohol consumption, though HPV is still by far the major cause of head & neck cancers (See previous University study in another chapter). Smoking can also influence cancer prognosis. When smoking is continued both during and after RT, it can increase the severity and duration of mucosal reactions, worsen the dry mouth (xerostomia), and compromise patient outcome. Patients who continue to smoke while receiving RT can have a lower long-term survival rate than those who do not smoke. Note the medical terminology installed again “can”: equally it might be “may not”!

Anti-smoking icon dies at 62: Debi Austin made famous in ad that showed her puffing through the hole in her neck (stoma) dies of throat cancer after 20-years living with cancer.

Early side effects
Early side effects include inflammation of the oropharyngeal mucosa (mucositis), painful swallowing (odynophagia), difficulty swallowing (dysphagia), hoarseness, lack of saliva (xerostomia), orofacial pain, Laryngeal radionecrosis, dermatitis, hair loss, nausea, vomiting, inadequate nutrition and hydration, and weight loss. All or any of these complications can interfere with, and delay treatment. To some degree these side effects occur in most patients and generally dissipate over time.
The severity of these side effects is influenced by the amount and method by which the radiotherapy is given, the tumor’s location and spread, and the patient’s general health and habits (i.e. oral sexual activity, continued smoking, alcohol consumption).

Skin damage (radiation-induced dermatitis):-
Radiotherapy can cause a sunburn-like damage (radiation dermatitis) to the skin which can be further aggravated by chemotherapy. It is one of the most common side effects of radiotherapy and can cause a little or a whole lot of pain and discomfort – everyone is receptively different. The dermatitis depend upon the radiation dose and can be mild, moderate and severe. The severity of dermatitis and healing time are greatly increased in patients taking radiosensitizing agents. My own personal experience I would not want anyone else to go through as the last 7/8 seesions of RT burnt my neck so badly that I had to have large dressings, soaked in Aqueous cream to stop the horrendous burning sensation, keep the entire neck clean & protected from outside germs & to help the skin to slowly heal. Note that if your neck is in this sort of condition you will probably need your partner to help you into bed and lower your head onto pillows.

It is advisable to keep the irradiated area clean and dry, wear loose-fitting clothes to avoid friction injuries, wash the skin with lukewarm water and mild soap (preferably synthetic soaps), and avoid exposure to potential chemical irritants, skin irritants such as perfumes and alcohol-based lotions, direct sun and wind, and local application of lotions or ointments prior to RT that might change the depth of radiation penetration.
There are a number of skin care products that can be used during radiation treatment to lubricate and protect the skin. These include aloe vera-based gels and water-based lotions. Although such preparations may provide symptom relief, none promotes or accelerates healing of the radiation-induced dermatitis.
Mild dermatitis starts improving with 10 days after completing of radiation, while severe dermatitis is associated with prolonged inflammation and healing time, resulting in skin fibrosis.
Skin cancer can rarely develop at the irradiated areas.
Wearing adhesive heat and moisture exchanger (HME) housing is not recommended during radiotherapy and the recovery period as the skin around the stoma usually become inflamed. Again, gently employ Aqueus Cream arond the area and it will soon heal up. Always remember this one important thing: you, yes YOU have got this far so sleep well and let each day come as it may for you are on the up!

Types of radiation therapy:
Most patients with for head and neck cancers are treated with external beam radiation therapy (using X-rays or gamma rays). The current standard of care is to use intensity-modified radiotherapy (IMRT). This method adjusts the beams to maximize radiation to cancerous tissue and not to normal tissue. This reduces side effects of radiotherapy. An individual face mask is made for each patient to insure accurate delivery of radiation. The number of treatments a person may get depends on the cancer type. Some patients get radiation only a single radiotherapy time while others get radiation once a day, 5 days a week, for up to 7 weeks. Our maximum in Britain is 33 consecutive treatments -and don’t I know it!
Other methods of radiation include:
• Brachytherapy (implanting radioactive source close to the cancer),
• intra-operative radiation therapy,
• Neutron beam radiation therapy ( using higher energy neutron beams),
• Proton beam radiation therapy ( a more precise radiation),
• Radiosurgery ( using Cyberknife®, Gamma Knife® and LINAC),
• TomoTherapy (combines precise 3-D imaging from CT scanning with highly targeted radiation beams delivered precisely to the cancer while minimizing surrounding tissues damage),
• Conformal radiation therapy (radiation beams are shaped to match the tumor’s 3 dimensional picture based on CT and/or MRI scans)
• Radioactive iodine (for thyroid cancer)

If that lot deoesn’t give you the ‘collywobbles’ then nothing will but in reality they are simply different types of treatment but all with the same goals. Your oncologist will sort through the options best suited to you and the blasting of those naughty cancerous cells will commence. ‘Girder your loins’ as they say (or simply ‘girder’ anything you fancy ‘girdering’ and think positive – these guys know what they are doing.

Common side effects:

These may or may not affect you, everyone is different. However it isn’t the worst thing in the world to have the knowledge at hand and you can easily google the following-

• Hair Loss

• Loss of taste

• Sense of smell diminished

• Dryness of mouth

• Tooth/teeth problems

• Itchy gums

• Dry itchy skin

• Irritating flakey skin

• Nausea

• Neck cramps

• Headaches

• Dirty yellow urine

• Trouble swallowing

These are some of many irksome ‘little blighters’ that may be brought about by chemo/radiotherapy or both. You can help yourself by keeping hydrated;ie, drink plenty of fluids. Any concerns whatsoever and your hospital will soon sort the problem out and provide you with fact sheets on all that concerns you – just remember that you must stay positive and simply take one day at a time. Good luck.