Radiation Therapy

Musaddiq Awan, MD, radiation oncologist, explains how radiation therapy works and how important it is to be precise when treating a head or neck tumor while avoiding healthy tissues around it. 

Radiation therapy works using electromagnetic radiation and, essentially, primarily X-rays — though other particles may be used — to target the tumor. It's important to be very precise in the process of aiming radiation therapy because radiation affects both normal cells and tumor cells. Normal cells can heal from radiation. Tumor cells don't heal from radiation as well. By precisely targeting the tumor, we're sparing the normal cells from toxicity.

We also cause some toxicity in the treatment process, and that's what we have to manage during treatment. It is important to be precise in using radiation therapy because you want to deliver a high, successful dose of radiation to treat and successfully cure the tumor while sparing the normal tissues that surround it.

Having expertise in head and neck cancer allows us to accurately target that tumor while sparing normal tissues and minimizing toxicity.

Stuart Wong, MD, medical oncologist, explains radiation therapy and its goals for head and neck cancer treatment. 

Radiation therapy for head and neck cancer is, in many regards, the cornerstone for treatment for patients with a newly diagnosed disease. Sometimes for a very advanced disease, radiation therapy is also an important part of their treatment plan. We are very committed to providing the latest techniques and the latest machinery to deliver that radiation therapy. In order to do this, it may need to be done on a clinical trial, and we are happy to provide these opportunities for our patients.

An important goal of radiation therapy trials for head and neck cancer is to improve outcomes — to improve survival, and this is the goal of a number of clinical trials we have with radiation therapy techniques. Some of our radiation therapy trials also try to present the best possible outcome, but limit the side effects associated with radiation. We have a number of clinical trials that are homegrown, and some clinical trials that are part of a nationwide network.

Musaddiq Awan, MD, radiation oncologist, explains the radiation therapy planning process for treating head and neck tumors as precisely as possible. 

To plan head and neck radiation, we want to precisely target both the tumor and define the areas we want to avoid.

We make a customized mask for each patient, and we then get a CAT scan.
We integrate that CAT scan with information to carefully design a plan, incorporating:
Additional imaging from an MRI or PET scan
Information from the surgeon that the surgeon details for us
Information from the pathology report
Our own experience with that particular cancer

We actually draw the areas on the CAT scan that we want to target and the areas we want to avoid. Those structures include:

Salivary glands — the glands that produce saliva
The mouth — where you have your taste buds as well as saliva
The throat — which allows you to swallow
The voice box — which allows you to speak.

In balancing tumor control and sparing those organs, we develop a personalized plan for you, and we try to balance the overall radiation doses to the tumor with the doses to those structures to maintain long-term quality of life.

For head and neck cancer patients, the purpose of the radiation mask is to keep people in the same position every day and to be able to aim that radiation as precisely as possible. With the mask, we can aim that radiation as precisely as two to three millimeters, so we can accurately target the tumor while staying away from normal tissues — including salivary glands, the voice box and swallowing muscles.

Musaddiq Awan, MD, radiation oncologist, describes the timeline and attention that goes into creating a radiation therapy treatment plan with the input of various team members for a customized approach. 

The overall time from radiation mask-making to radiation planning typically is about two weeks. In that two-week period, the doctor spends several hours working on, designing and drawing out the tumor and normal tissue structures on each slice of the CT scan we make for radiation planning.

From there, we define a set of goals for our radiation planning team to achieve. Then we go back and forth in evaluating that radiation plan with our planning team. That can take a number of days for the planning team and a number of iterations between the doctor and the planning team.

Once we're happy with the plan, we have a physics team to run quality assurance to make sure that the plan is accurately delivering what we think it is delivering. Then we approve the plan. Outside of the consult and all the patients we see on treatment, we typically spend several hours for each patient just to make sure it's right for their particular circumstance.

Musaddiq Awan, MD, radiation oncologist, explains why it is essential to personalize head and neck radiation therapy based on the location and size of a patient's tumor. 

Radiation treatment is the ultimate in personalized medicine — especially to the head and neck. Every patient has a different tumor with a different tumor size, near different critical structures and critical organs. Managing and personalizing the radiation treatment to that patient has to balance between tumor control and toxicity.

We take a painstaking process to adequately define the tumor and the organs surrounding that tumor, and we develop a complex radiation plan to optimally do that. For each individual patient, I have to weigh the risks and balances of that process. In doing so, I create a plan that's really customized for them and their particular anatomy and tumor.

When we deliver radiation treatment, we want to ensure that we give you just enough radiation to cure your cancer and give the best chance of tumor control; while not giving any more than that, so that we don't cause excess toxicity.

Working that balance and understanding where the radiation is delivered and where it's not being delivered is important to optimize cancer control and give you the best quality of life after treatment.

Musaddiq Awan, MD, radiation oncologist, describes radiation therapy short-term and long-term side effects for head and neck cancer. 

Radiation treatment for head and neck cancers is hard because it has a lot of short-term side effects, and it may leave patients with long-term side effects. Short-term side effects that patients may experience during radiation include:

Sunburn-like reaction on the skin
Sunburn-like reaction in the in their mouth or the mucous membranes which are kind of the skin of the mouth
Dry mouth
Poor taste

A combination of dry mouth, poor taste, sores in the mouth and throat are a recipe for people to lose weight and not eat that much. We use alternative diets and try to avoid a feeding tube as this really helps people maintain the best quality of life. All of this requires a lot of skill and practice.

Long-term effects with radiation also occur. These include:

Some long-term alterations in taste
Long-term dry mouth that can promote tooth decay and cause potential dental injury or injury to the bones of the jaw
Long-term issues with swallowing
Potential damage to the voice box and swallowing structures.

Understanding how to optimally spare those structures allows us to minimize those risks and give patients the best long-term quality of life.

Musaddiq Awan, MD, radiation oncologist, explains how the recovery process from head and neck radiation therapy takes time and his team's ultimate goal of improving the patient's quality of life after treatment. 

Recovery from radiation therapy to the head and neck typically takes several weeks to several months. Patients often initially struggle with recovering from the sores and skin reaction in their mouth, but taste changes and dry mouth can persist for weeks months or even years — so that process is gradual.

Recovery from the side effects of head and neck radiation treatment can be very challenging, but our team is here to get you through that immediate post-treatment period and to follow you long term to manage all the side effects and issues that may arise and optimally improve your recovery and quality of life.

Musaddiq Awan, MD, radiation oncologist, explains how the right technology in the hands of an experienced head and neck cancer specialist is important to a patient's outcome and how it can reduce side effects and treatment complications. 

Technology is very important in radiation treatment for the head and neck. We've come so far over the past 20 to 30 years. We used to radiate everything when we were treating head and neck cancers — leaving patients with long-term side effects and a lot of complications from treatment.

As our precision increased, we can spare patients many of the side effects and lots of complications from treatment — improving their overall quality of life. Having the technology in the right hands is also important. You can use a carving knife to make a statue, but the statue is not going to look like anything if you don't know how to use it.

It's the same with radiation treatment. If you don't have the expertise using that technology, you'll not get the best plan for each individual patient.

For modern radiation planning for the head and neck, we use intensity-modulated radiation treatment. Intensity-modulated radiation treatment allows us to precisely target a tumor while avoiding critical structures and creating complicated radiation dose distributions to do that. That technology has to be in the right hands to design that plan and to make sure it's the best plan for each individual patient. Even though many facilities have access to intensity-modulated radiation — most do, having those tools in the right hands is critical to create the optimal treatment plan for that patient.

Musaddiq Awan, MD, radiation oncologist, describes how advances in technology, imaging and clinical trials continue to improve radiation therapy. 

Radiation therapy has improved over the years due to the ability to better target and develop more accurate radiation plans. That includes:

Better imaging before radiation treatment
The ability to actually deliver plans faster
The ability to develop more accurate treatment plans.

Because of these advances, we're able to more accurately define what we want to treat. We treat patients with narrow and narrower margins so that we're able to limit toxicity.

Here at our institution, we're also using the MR-guided linear accelerator (MR-Linac), which allows us to visualize the tumor as it changes throughout the course of treatment. And we have clinical trials that are evaluating the ability to better target these tumors or adapt radiation on a daily or weekly basis based upon tumor shrinkage and tumor response to treatment.

Stuart Wong, MD, medical oncologist, talks about radiation therapy clinical trials.

We have a number of radiation therapy clinical trials that use a new technique to deliver radiation in a shorter amount of time with larger doses of radiation. This has been a technology that has been used in a number of different types of cancers, but not yet pioneered in head and neck cancer. And so we offer a number of clinical trials that use this new technology.