Long Term Side Effects of Radiation Therapy for Head and Neck Cancer Survivors

Written by: James Suen, MD

It is a privilege for me to share some of my experiences that may or could affect your health. I have had the opportunity to treat patients with head and neck cancer for more that 50 years and continue to do so. I have treated thousands of patients and followed them for as long as 50 years, so I have seen both short and long term problems. I have edited 4 major medical textbooks on “Cancer of the Head and Neck” with one of my close friends and colleagues, Dr. Eugene Myers at the University of Pittsburgh.

It is common for Head and Neck cancer specialists to tell patients that if they survive for 5 years with no recurrence, that they are considered cured and do not need regular follow-up—and the patients may not see their doctors again. I commonly will tell patients that they are cured of that cancer after 5 years, but I continue following my patients for many years and as long as 50 years. This has given me the opportunity to see long term problems that may not occur until 10 or more years after treatment. I wanted to discuss these problems and how I treat them.

As most of you are aware, most head and neck cancers are treated with surgery, radiation therapy, and chemotherapy. In the past, most of the cancers were caused by tobacco use but in the past 10-15 years, we have found that the majority are now related to Human Papilloma Viruses, which can be sexually transmitted. Also these HPV related cancers can have a better prognosis and often can be treated with less combined therapy. However, radiation is still commonly one of the main therapies used and I have found that radiation has many long term side effects which patients need to be aware of.

I have seen many of my patients begin to have problems swallowing around 8 to 10 years after their radiation therapy and it becomes progressively worse with time.

This can become severe and result in aspiration and pneumonias. If treated with simple esophageal dilatations as needed, it can allow patients to continue to eat and swallow orally. These esophageal dilatations can be done by the otolaryngologists or by gastroenterologists and are easy and quick to perform. There are different ways to dilate the esophagus and should be easy to perform. If you are having problems swallowing and it feels like food stops behind your larynx, it is usually due to scarring of the Cricopharyngeal muscle which is the beginning of the esophagus. Radiation therapy causes severe mucositis of the throat and upper esophagus and when the patients do not swallow during the latter part of radiation therapy, the healing of the lining of your throat scars down. This is why I encourage my patients to swallow something every day to try to decrease the scarring as the mucositis subsides after radiation therapy is completed. As most of you have experienced, a gastrostomy tube is inserted before or during treatment and patients will avoid swallowing because of the pain. I encourage swallowing liquids throughout the radiation therapy and afterwards to keep the Cricopharyngeal muscle functioning. This can help prevent the esophageal stenosis or make it less severe.

Another problem is voice and breathing because of the radiation therapy effects on the vocal cords and/or the nerves to the vocal cords. A small percent of patients who have radiation therapy will have this problem and it can paralyze or fix (scar) the vocal cords so that they cannot open making it difficult to breathe and talk. If this happens, a tracheotomy may be necessary. I have been able to treat paralyzed vocal cords by using a CO2 laser to remove part of the posterior 1/3 of the vocal cords to enlarge the airway. This does give some hoarseness which recovers in a few weeks and gives them better breathing for months or even years.

The other problem I wanted to bring to your attention is that radiation therapy has severe effects on the teeth and the ability to heal.

After radiation therapy to the oral cavity, it is dangerous to extract teeth because it is common to cause Osteoradionecrosis of the bone from a dry socket. Osteoradionecrosis is a major problem and can cause severe pain, difficulty eating, and even fractures of the jaw. I feel it is safe to repair cavities or do root canals but extractions should not be done routinely. Also I do not feel that Hyperbaric Oxygen can protect you from 4 Osteoradionecrosis and is very expensive. It is important to use Fluoride treatments to your teeth daily and to have dental hygiene cleaning routinely for the rest of your life to help prevent dental decay.

A common question I have been asked is are dental implants safe to have after radiation therapy. It can be done safely but I have seen several patients who had dental implants which got infected and caused osteoradionecrosis and fractures requiring major surgeries.
Another problem I have found is fibrosis or scarring of the neck muscles from radiation therapy and it can cause severe muscle spasms. This is a late effect also. I treat these with Botox injections and it can stop or decrease the spasms for about 4 months and then require repeat Botox injections.

The radiation therapy effects do not “wear off” with time but actually continue to progress. Most head and neck cancer specialists do not discuss these late, long term problems with their patients and that is why I offered to do this article to make you aware of these potential problems. Hopefully this is helpful to you. You may have experienced other problems which I did not discuss and it would be good to respond to SPOHNC so that you can share the problems with others who have been treated.

I appreciate the opportunity to share some of my experiences which may have affected you or will affect you. Knowledge can be powerful.

Editor Note: Dr. James Y. Suen is a professor in the Department of Otolaryngology — Head and Neck Surgery. Dr. Suen received his medical degree from UAMS in 1966. He completed residencies in general surgery and otolaryngology at San Francisco General Hospital and UAMS.

A captain in the United States Air Force, he completed a fellowship in ptolaryngic pathology at the Armed Forces’ Institute of Pathology in Washington, D.C., and was an advanced senior fellow in head and neck surgery at M.D. Anderson Cancer Center in Houston.

He is certified by the American Board of Otolaryngology. Dr. Suen is a fellow in the American Academy of Otolaryngologists and the American Head and Neck Society, of which he is past president.

Share This Post!