Radiotherapy Dosing for Head and Neck Cancer

Definitive Radiotherapy Dose Recommendations

The National Comprehensive Cancer Network (NCCN) guidelines recommend delivering 70 Gy in 35 fractions (2 Gy per fraction) over 7 weeks to gross disease when using standard fractionation with concurrent chemotherapy 1, 2
The NCCN guidelines specify a range of 66-74 Gy at 2.0 Gy/fraction for primary tumor and gross adenopathy 3
Do not exceed 75 Gy using conventional 2.0 Gy fractionation, as doses above this threshold lead to unacceptable rates of normal tissue injury 3

Either standard once-daily radiotherapy (70 Gy in 35 fractions) or accelerated fractionation may be used after discussing patient preferences and the risks/benefits of both approaches 1, 2
The Danish Head and Neck Cancer Group trial defined accelerated radiotherapy as 66-68 Gy delivered at six fractions per week (instead of five), completing treatment in 6 weeks rather than 7 weeks 1, 2
Altered fractionation is strongly recommended for stage IVA-IVB disease treated with definitive radiotherapy alone 1, 2

Deliver 60-66 Gy at 2 Gy/fraction once daily to regions with microscopically positive surgical margins or extracapsular nodal extension 1, 2
Higher doses (60-66 Gy) with or without chemotherapy are specifically recommended for high-risk features 3

For T1 N0 M0 nasopharyngeal cancer tumors, 66-70 Gy with standard fractionation achieves 80-90% local control 5
For locally advanced disease, concurrent platinum-based chemotherapy with radiotherapy followed by adjuvant cisplatin/5-FU is standard 5

Do not use induction chemotherapy routinely for oropharyngeal squamous cell carcinoma, as it has not proven additional benefit 2, 5
Avoid exceeding 75 Gy with conventional fractionation due to unacceptable normal tissue injury rates 3

IMRT is widely used and reduces long-term toxicity to salivary glands, temporal lobes, mandible, auditory structures, and optic structures in oropharyngeal and nasopharyngeal cancers 3