Head and Neck Cancer Radiation Therapy

Radiotherapy can cure a cancer of the throat and leave the voice box in place. In the trial that settled it, 88 percent of patients kept their larynx.

Cancers of the mouth, throat, voice box, nasopharynx and salivary glands are treated with radiotherapy either instead of surgery, to keep speech and swallowing intact, or after it, to clear cells the surgeon could not see. The usual course runs seven weeks, with cisplatin alongside. A meta-analysis of 87 randomized trials found that adding chemotherapy during radiotherapy raises five-year survival by 6.5 percentage points, and the modern beam-shaping technique cut lasting dry mouth from 74 to 38 percent of patients in a British trial.

What radiotherapy does in head and neck cancer

Most head and neck cancers are squamous cell carcinomas. They start in the moist lining of the mouth and throat. Squamous cells are sensitive to radiation, which gives doctors a choice that exists in few other cancers. Seven weeks of radiotherapy with chemotherapy cure a tumor of the voice box or the back of the throat in most patients, and the organ stays where it is. Six weeks of radiotherapy to the operated area lowers the chance of return after surgery for a large tumor or one that has reached the lymph nodes. For the few tumors that cannot be cured, a shorter course shrinks them enough to relieve pain, bleeding or a blocked airway. Intensity modulated radiotherapy, IMRT, is the technique. A linear accelerator delivers it while the head rests in a mask, and the beams are shaped around the salivary glands, the spinal cord, the swallowing muscles and the jaw. At Biruni Hospital the machine is an Elekta Versa HD. A scan on the treatment couch before each session confirms the position, and the medical oncology team on the same site gives the cisplatin, once a week or once every three weeks, during the course.

Site by site

Each site has its own rules.

Oropharynx, the back of the throat

Tonsil and tongue-base cancers have changed in the past twenty years. Human papillomavirus, HPV, now causes many of them in place of tobacco, and the two kinds behave differently. Both get chemoradiation as the standard curative treatment. The HPV status, which the pathologist reports as p16, predicts the outcome more reliably than anything else, and patients with the HPV type often ask whether a milder treatment would do. A large trial answered that question with a clear no.

Larynx and hypopharynx, the voice box and the lower throat

An advanced cancer of the larynx used to mean removal of the voice box, a permanent opening in the neck and no natural voice. Radiotherapy with cisplatin keeps the larynx in most patients. The treatment is harder. Surgery remains the better choice when the tumor has destroyed the cartilage or the larynx no longer works, since a preserved organ that cannot swallow or protect the airway helps nobody.

Mouth, nasopharynx and salivary glands

Tongue, gum and floor-of-mouth cancers go to surgery first. Radiotherapy follows when the margins are close, the nodes are involved or the tumor is large. Nasopharyngeal cancer sits behind the nose where no surgeon can reach, and radiotherapy with cisplatin cures the majority of patients even at advanced stages. Salivary gland tumors are operated on and irradiated afterward when the grade is high or the facial nerve was close.

After surgery

Postoperative radiotherapy starts within six weeks of the operation, once the wound has healed. It covers the tumor bed and the neck. Cisplatin is added when the pathologist finds cancer at the cut edge or spread through the capsule of a lymph node, because two randomized trials showed better control of the disease with it in exactly those two situations and in no others.

The trials behind the treatment

Five trials shaped the standard. Each earns its place below.

Chemotherapy during radiotherapy

6.5 percentage points

Absolute gain in five-year survival when chemotherapy is given during radiotherapy, from 50 trials in the MACH-NC meta-analysis of 16,485 patients, with a hazard ratio for death of 0.81. Chemotherapy given before radiotherapy helped less, and the benefit of any chemotherapy fell with age. Pignon and colleagues, Radiother Oncol, 2009.

What it means for you

Cisplatin during the course is the standard for fit patients under 70 with a locally advanced cancer. Over that age, or with kidney disease, hearing loss or poor general health, the drug is dropped or replaced. Doctors decide person by person.

Keeping the voice box

88 percent

Patients with an intact larynx two years after radiotherapy with concurrent cisplatin, against 75 percent after chemotherapy followed by radiotherapy and 70 percent after radiotherapy alone, among 547 patients with advanced laryngeal cancer. Survival was the same in all three groups. Severe side effects during treatment were 82 percent with chemoradiation against 61 percent with radiotherapy alone. Forastiere and colleagues, N Engl J Med, 2003.

What it means for you

Chemoradiation keeps the larynx. It also takes the harder road during treatment, so patients who choose it should expect a sore throat that stops normal eating for several weeks and should have the feeding support planned in week one, long before it is needed.

HPV changes the outlook

82.4% vs 57.1%

Three-year survival in HPV-positive and HPV-negative oropharyngeal cancer among 323 patients treated with chemoradiation in a randomized trial. After adjustment for stage, age and smoking, HPV-positive disease carried a 58 percent lower risk of death, and every extra pack-year of smoking raised the risk. Ang and colleagues, N Engl J Med, 2010.

What it means for you

Ask for the p16 result before any planning conversation. It shapes the outlook more than the size of the tumor does, and it separates patients who may one day be candidates for gentler treatment from those who need everything the standard offers.

Can cisplatin be swapped for something milder?

77.9% vs 84.6%

Five-year survival with cetuximab and with cisplatin, each given alongside radiotherapy, among 805 patients with HPV-positive oropharyngeal cancer in the RTOG 1016 trial. The cancer came back in the head and neck in 17.3 percent with cetuximab against 9.9 percent with cisplatin, and side effects were no milder. Gillison and colleagues, Lancet, 2019.

What it means for you

Cetuximab, an antibody that some clinics present as a gentler alternative, proved worse. Cisplatin stays the standard. A patient who cannot take it should be told plainly that a different drug is a compromise.

Sparing the salivary glands

38% vs 74%

Patients with troublesome dry mouth a year after IMRT planned to spare the parotid glands and after conventional radiotherapy, in 94 patients with throat cancer. Saliva recovered with IMRT, quality of life was better, and tumor control was the same. Nutting and colleagues, Lancet Oncol, 2011.

Before anyone books a flight

Four things have to be settled first. The order matters.

1. Dental work. Any tooth that is decayed, loose or infected inside the future beams comes out at least ten days to two weeks before the first session, because an extraction from an irradiated jaw can fail to heal for years. A panoramic X-ray and a dental review are the first appointments of the course, and the reason to arrive early.
2. The sequence. Surgery first or radiotherapy first is a decision for a tumor board of surgeons, radiation oncologists and medical oncologists, made from the scans and the biopsy before travel. A patient who has already had surgery should send the pathology report, since the margins and the nodes decide whether cisplatin is added.
3. Smoking and alcohol. Both make radiotherapy work less well and side effects worse. Stopping at diagnosis is part of the treatment.
4. Time. Seven weeks of daily sessions plus planning means eight to nine weeks away from home. Patients who cannot commit to the whole course should be treated near home, because a course broken in the middle is worse than either choice made cleanly.

The seven weeks, step by step

1. Week 0. Consultation, tumor board, dental review and extractions, blood tests, hearing test if cisplatin is planned, a dietitian visit to record weight and plan feeding, and a speech therapist visit to record swallowing and teach the exercises that keep the muscles working.
2. Planning. The mask is made, a planning CT is taken in it, with an MRI or PET-CT fused to it where the tumor is hard to see, and the doctor outlines the tumor, the nodes and every organ to protect. The physicist builds the plan over three to seven working days.
3. Weeks 1 to 2. Treatment begins. Few symptoms yet. Cisplatin is given on day one, and the first weekly review checks blood counts and kidney function.
4. Weeks 3 to 4. The mouth and throat become sore, taste fades and saliva thickens. Mouthwashes, pain relief and a soft diet start. Weight is checked weekly, since every kilogram lost changes how the mask fits.
5. Weeks 5 to 7. The hardest stretch. Swallowing hurts, and many patients need liquid pain relief and a feeding tube, either through the nose or directly into the stomach, to keep calories going in. The skin of the neck reddens and may peel. The team sees you daily.
6. The two weeks after. Symptoms peak and then turn. Most patients feel the corner has been turned by the end of the second week after the last session, and that is the point at which the flight home makes sense.

Side effects, and what the team does about each

Head and neck radiotherapy has more side effects than radiotherapy anywhere else in the body. The lining that reacts first is the lining you eat and speak with. The table separates what happens during the course from what stays afterward, and the column on the right shows that each effect has an answer, even where that answer is time.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

When the course has to change

Change during a head and neck course is the rule. Weight loss loosens the mask and shrinks the tumor. Many centers take a new scan and build a new plan in the fifth week as a matter of routine. Low blood counts or a rise in kidney tests delay or cancel a cisplatin dose while radiotherapy continues. Radiotherapy itself must not stop. Dehydration or pain that tablets cannot control leads to admission for fluids, pain relief by drip and a feeding tube, and the daily sessions go on from the ward, with a porter and a wheelchair. Because chemotherapy, radiotherapy and the ward are on one site at Biruni Hospital, a patient who is admitted is taken to the machine each day without an ambulance.

A missed session is added at the end

The total dose and the overall time both matter in this cancer, and gaps in treatment lower the chance of cure. Two sessions on one day, six hours apart, make up lost ground. Keep a margin of a week before the return flight.

Weeks in Istanbul, cost and the trip

The length of stay is the first thing to fix, and the table gives the three usual cases.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

These figures follow the schedules used in the trials and the programs that Turkish hospitals publish for international patients, which quote six to seven weeks of daily treatment plus preparation. Nine or ten weeks is longer than most visa-free entries allow. The international patients office sends an invitation letter with the appointment confirmation ten days before travel, naming the hospital and the treating doctor, and for a stay of this length it belongs in a visa application.

The number of sessions sets the cost first, followed by the technique, the cisplatin cycles with their blood tests, the planning imaging, the mask, dental extractions, dietitian and speech therapy visits, feeding tube placement, and any admission for supportive care. It is a longer list than for most radiotherapy. Published packages in Istanbul cover the consultation, planning, all sessions and weekly reviews, an interpreter and transfers. They leave out chemotherapy drugs, the hotel, flights, dental work and admissions. Age, kidney function, hearing, diabetes and previous radiotherapy to the neck all change the plan. A quote follows the doctor's review of the scans and the biopsy, and that review costs nothing.

Nobody should go through this alone. One coordinator handles the case from first contact to departure, in English, Arabic, French, Russian, Serbian, Romanian or Spanish, or through an interpreter, and stays reachable through the hard weeks. An apartment-style hotel near the hospital, shared with a relative who can prepare soft food, suits a stay of this length, and the hospital kitchen prepares halal, vegetarian and diabetic meals in soft and liquid forms for patients who are admitted. A prayer room is on site. Request a female doctor, if you wish, when you first write.

After you fly home

Recovery outlasts the treatment by a wide margin. Plan for that too.

Recovery takes months, and some care lasts for life

Taste returns over three to six months. Saliva improves for up to two years. Swallowing exercises continue for at least six months, because the muscles stiffen if they are not used. Fluoride trays or gel are used every day for life, and no dentist should extract a tooth from the irradiated jaw without contacting a radiation oncologist first.

Head And Neck Cancer Radiation Therapy FAQ