Future Head and neck radiotherapy treatments in the upright position

Radiotherapy for head and neck cancers is typically given with the patient lying on their back on a treatment couch. A thermoplastic mask is worn over the head, neck, and shoulders and is attached to the treatment couch, securing the patient in a stable position to ensure treatment is delivered to the right place.

We have heard from patients time and time again how tough they often find treatment in this position either because of the close-fitting mask, lying down flat on their back, or from having to manage thick oral secretions caused by treatment whilst lying in that supine position.

So could upright treatment be the answer to some of the challenges patients have to face on a daily basis in order to receive their life-saving treatment?

Studies are beginning to provide encouraging evidence to support upright radiotherapy in providing clinical and psychological benefits for patients.

Easier breathing

Research has shown that when lying down, our lung volume decreases, and the effects of gravity make it harder to inflate the lungs. Typically, when we are trying to regulate our emotions, we are told to take deep breaths, so standing up for treatment will allow for the greater lung expansion needed to achieve this. Also, the importance of oxygen in radiotherapy effectiveness has been known since the 1950s, with tumors located in well-oxygenated regions responding three times better to radiotherapy. This is an area for future research to confirm if there is better oxygenation upright due to better lung inhalation.

Looking back to look forward

A study by Lynn J. Verhey Ph.D et al in 1982 compared the motion and reproducibility of head and neck treatments in both seated and supine positions. The study found that patients immobilized in the seated position with a bite block and a mask had a mean movement of about 0.5 mm with a standard deviation of 0.3 mm. In comparison, patients immobilized in the supine position with their necks hyperextended for submental therapy (an area located at the chin) had a mean movement of about 1.4 mm with standard deviations of 0.9 mm. This study also measured the accuracy between multiple treatments and seated patients had the highest number of sub-millimetre accuracy setups.

The head and neck region is intricate and accuracy of radiation delivery is paramount, therefore we hope to further improve upon these results in our research, also considering the enhancements in the delivery of radiotherapy since 1982.

Decreasing the fear of swallowing

A side effect of radiotherapy to the head and neck region is thick oral secretions and the confines of the thermoplastic mask can sometimes make it difficult to manage these. In 2017 Alghadir, Zafar and Iqbal found that when the head is extended, as required for supine treatment, the opening of the airway narrows making it harder to take deep breaths and also to swallow these secretions. The participants in this study found that self-perceived difficulty while swallowing was 6 times higher lying down than sitting upright.

Unmanageable secretions, heightened anxiety and the very serious health implication of aspirating these secretions can all cause unplanned breaks in a persons treatment and the consequences of these can have an impact on someone’s prognosis. Other researchers have tried to overcome the challenges of unmanageable secretions by placing the patient lying face down on a treatment couch. Being upright and allowing gravity to do its work will improve comfort during treatment for those experiencing these side effects.