Articles
Management of Radiation Toxicity in Head and Neck Cancers

https://doi.org/10.1016/j.semradonc.2017.04.008Get rights and content

Head and neck cancers account for approximately 3% of all cancers in the United States with 62,000 new cases diagnosed annually. The global incidence is approximately 700,000 new cases a year. There has also been a recent increase in human papilloma virus–related oropharyngeal cancers. External beam radiation therapy (RT) is commonly used as an effective therapy for head and neck (H&N) cancers. This is used as a definitive treatment (alone or in combination with chemotherapy) or as an adjuvant treatment after surgical resection of the tumors. Because of the complex anatomy of the H&N region, several critical structures in and around the area receive radiation treatment. This includes the neural structures (brainstem, spinal cord, and brachial plexus), salivary glands, mucosa, major blood vessels, and swallowing musculature. Careful RT planning is necessary to avoid or mitigate the side effects of treatment. This review discusses some of the major acute and late side effects of RT for H&N cancers and provides evidence-based guidelines for their management. Patient-reported outcomes and quality-of-life implications are also discussed.

Introduction

The incidence of head and neck cancers (HNC) in the United States is approximately 62,000 cases diagnosed per year.1 Worldwide, the incidence is more than 10 times this number with approximately 686,000 new cases.2 Radiation therapy (RT) plays an essential role in the definitive, postoperative and palliative treatment of HNC. However, RT is associated with significant side effects during and after the completion of therapy. This review examines some of the commonly noted toxicities of RT and their management strategies. The list below excludes concurrent chemotherapy-related acute and late side effects such as nausea, vomiting, nephrotoxicity, and ototoxicity.

Section snippets

Mucositis

Mucositis is a condition characterized by inflammation of the oral mucosa resulting in pain and burning sensation with consequent compromised oral intake in patients with HNC undergoing RT. Patient-related factors that contribute to the development and severity of mucositis include poor orodental hygiene, smoking, alcohol intake, and consuming hot and spicy foods.

Mucositis is a very common side effect seen in 90%-100% of patients undergoing RT alone or with concurrent chemotherapy. Trotti et al3

Xerostomia

Xerostomia is the sensation of dryness in the mouth and is a very common and significant complaint in patients undergoing head and neck (H&N) RT. It is an acute symptom starting as early as the second week of RT and persists as a subacute and late side effect of treatment. Patients complain of dry mouth and thick sticky saliva that is difficult to swallow or spit out. This causes significant discomfort with feelings of gagging and nausea. IMRT has resulted in a significant improvement in

Dysgeusia

Dysgeusia refers to the altered taste or lack of taste experienced by patients undergoing H&N RT. Loss of taste precedes the development of mucositis or clinically significant xerostomia. It usually starts around a dose of 10-16 Gy and taste is almost completely lost by 24-30 Gy. The combined effect of dry mouth, taste changes, and pain due to mucositis results in reduced oral intake, weight loss, and reduced QOL. In patients receiving concurrent chemotherapy these symptoms are further

Dermatitis

Radiation-induced skin reactions are seen in up to 95% of patients.41 These can be in the form of redness (erythema), pain or burning sensation on the skin, and dry or moist desquamation. The use of high-energy megavoltage radiation reduced the rate of skin reactions as compared to cobalt-60 treatment. However, the use of IMRT techniques can result in increased skin dose due to the tangential incidence of beams on the skin.42 Radiation reactions on the skin typically parallel the development of

Radiation Caries and Osteoradionecrosis

Radiation caries refers to tooth decay or breakdown of teeth that can occur because of RT. This is a rapidly progressing condition that can involve the dental pulp resulting in the loss of involved teeth. One of the major contributing factors is RT-induced xerostomia. Because of radiation to the salivary glands, the composition of the saliva changes and becomes thick and sticky and the pH changes from 7.0 to 5.0.52 This results in reduced buffering capacity of the saliva and makes it more

Dysphagia

Radiation-induced dysphagia is a significant radiation toxicity resulting in difficulty in swallowing during the oral, pharyngeal, or esophageal phases of swallowing. It may be associated with overt or silent aspiration. Some patients may present with dysphagia at the outset because of tumor involvement of the swallowing structures. This condition should not be classified as a radiation-related complication.

This RT-related complication has recently received significant attention in literature

QOL Implications

So far, the focus of this review has been on the management of toxicities, primarily as documented by physicians or other healthcare providers. Indeed, for decades, the classic approach for reporting toxicities in oncology has been through the National Cancer Institute׳s Common Terminology Criteria for Adverse Events (CTCAE). Of note, approximately 10% of the ~800 items on this list represent symptoms, such as fatigue or nausea. However, studies have shown that clinicians tend to underreport

Conclusion

RT for HNC is associated with significant acute and late side effects with a consequent impact on patient QOL. The use of new technologies and novel approaches such as IMRT and adaptive RT has demonstrated the potential to alleviate or minimize some of these side effects. Detailed investigations into the impact of these measures on PROs and QOL will allow constant modulation and improvement in physical and biological means to reduce or treat these side effects.

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    Conflict of interest: The authors report no conflict of interest pertaining to any of the material presented in this manuscript.

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