Head and Neck cancer: Understanding side effects of radiotherapy

Early side effects (during or soon after treatment)

Early (sometimes called acute) side effects happen during and soon after radiotherapy.

General effects for all parts of the head

• Feeling very tired or fatigued: You might feel very tired during and after your treatment. It’s important to get plenty of rest but sometimes you will still feel really tired, even with lots of sleep. Some tiredness can be caused by having cancer and having cancer treatment, and some can be caused by travelling to and from hospital every day for treatment.
• Skin reactions: You might notice a change in colour, swelling, itching, or changes in the texture of your skin where you’re treated. For people with lighter skin tones these changes can be pink, red or darker than the surrounding area. People with brown and black skin tones might have colour changes such as maroon, purple, yellow or grey pigment changes. Or the skin can look darker than the surrounding area. These changes usually improve after treatment, but this can take 4 to 6 weeks in some cases.

• Hair loss: Hair loss can happen in the area you are treated. Some hair loss might be permanent. You can consider wearing a wig or hat if you feel self-conscious about hair loss. However, it is becoming more common for people to accept hair loss and choose not to cover it, as hats and wigs can be uncomfortable or too hot. For people who are able to grow a beard, it is advised to avoid wet shaving during treatment and only dry shaving with an electric shaver. 
• Anxiety: Low mood and feeling down is very common and expected. It can help to talk to other patients and support groups who understand what you are going through.

• Pain and soreness: Radiotherapy can cause pain and soreness in the area being treated. It can make your mouth and throat sore, and painful, making it hard to swallow. Inside the mouth can look red for people with lighter skin tones but for people with brown and black skin the area can also sometimes have a purple tinge. It is common to get ulcers, thrush and infections in your mouth. This usually starts a few weeks into your treatment. It might be tough to eat because swallowing can be difficult. You can get support from a specialist pain management team ask your treatment team if pain becomes an issue for you. Be very honest with your team. Don’t leave asking for pain relief until it is too painful
• Dry mouth and thick mucus: Radiotherapy affects the glands that make saliva, leading to a dry mouth or thick mucus. Sometimes a nebulizer can help relieve thick mucous; this is a machine that will help break the mucous down. A dry mouth might be temporary or permanent. Keep your mouth moist by drinking water and using salt water Some patients say they find saliva pastilles helpful. However, your mouth might be too sore for saliva pastilles during treatment. As your mouth heals, these can be very helpful.
• Changes in taste and appetite: Food and drink might taste different. For example, sweet things can taste salty or metallic. Talk to a specialist dietician for tips on dealing with taste changes. It may be really difficult to keep a good appetite due to all the side effects and your mouth and throat being so sore. This is when you may need a feeding tube or build-up drinks. These challenges can last a long time or be permanent.
• Weight loss: It can be difficult to eat and maintain a balanced diet.
• Feeling or being sick: This is a common side effect as taste and sensation in the mouth changes. Food and drink won’t taste the same.
• Chest infection: You might need medication if you get a chest infection.
• Speech and language issues: Speech and language therapists can help support you. Not only with speaking, but with swallowing and other related issues. It is important to get a referral and receive the right support as soon as possible. There are voice and speech phone Apps available that can be helpful. Previous patients have suggested the Project Relate voice App or Speech Assistant. Both are free on android phones but have a price on iPhones. These Apps can help with communication when it’s difficult to talk.

Side effects when treating the upper head 

• Ear problems: Swelling in the eustachian tube (which connects the middle ear to the back of the nose) can cause ear pain or a blocked sensation. Talk to your treatment team if you have ear discomfort or experience temporary hearing loss.
• Red or watery eyes. You may have dry eyes if your sinus area is being treated, or near the treatment area.
• Nose irritation: The lining of your nose can become irritated and feel blocked.
• Loss of smell: This is a common side effect.

Side effects when treating the lower head

• Cough: Irritation in the throat and upper part of the windpipe can cause a cough.
• Voice changes (hoarseness): Your voice might become hoarse if the voice box gets irritated and swollen from the treatment. Rest your voice and let your treatment team know if it becomes a problem. 

Side effects when treating the neck

• Breathing difficulty: Radiotherapy can cause inflammation and swelling in the neck area, leading to breathing problems. In rare cases, this swelling can cause noisy breathing. If you have trouble breathing, seek medical help straight away.
• Cough: Irritation in the throat and upper part of the windpipe can cause a cough.
• Voice changes (hoarseness): Your voice might become hoarse if the voice box gets irritated and swollen from treatment. Rest your voice and let your treatment team know if it becomes a problem.

What can help with these early side effects?

• Preparation: Don’t wait for the pain to become too much. Ask for medication or a referral to the pain management team. A dietitian can help you find ways to keep eating well. Ask your treatment team about mouthwashes and saliva products that can help.  You may be encouraged to have a feeding tube fitted before starting radiotherapy. This can help you receive nutrients and help maintain your weight. If you lose weight and change shape your radiotherapy mask will not fit, and a new mask and treatment plan may be needed.

• Rest and care: Take breaks, get plenty of sleep, and be kind to yourself during treatment.
• Drinking fluids: Drinking plenty of fluids such as water, juice and squash can help with fatigue and tiredness caused by your treatment. It can also help flush out toxins in your body caused by treatment. You can try diluted juice if you don’t like water.
• Skin care: Your treatment team can suggest creams to soothe your skin. Sometimes, extra care is needed if the skin breaks down in the treatment area. Wear loose clothing and stay out of the sun. 
• Get help: It is really important to access support early from dietitians, pain management team, physiotherapists, speech and language teams and other specialists. Managing early symptoms like eating problems, swallowing and stiffness is vital to long-term recovery.
• Stay in touch: Always communicate with your treatment team about any side effects or concerns. They are there to help you feel better and support you throughout your treatment.
• Seek support: Speak to other patients and find support groups who understand what you are going through, they can help support you.
• Keeping active: Sometimes gentle movement can help you feel better, both during and after treatment. Your treatment team can tell you what is safe for you to do. 
• Alcohol use: Please follow the NHS guidelines on safe drinking levels and any instructions you get from your team on what is right for you, your diagnosis and your treatment. If in doubt, please ask your team. 
• Sexual changes: Talk to your team if you are experiencing issues with sex and cancer and they can offer advice.
• Stop smoking: If you are looking to stop or reduce smoking, there are services available to help you.