Radiation Oncology / Supportive CareCTCAE v5.0

Radiation Toxicity Atlas

Grade radiation-induced adverse events and review practical, evidence-informed supportive-care options.

Educational clinical reference only. Grade using the full CTCAE v5.0 term and local protocol. Exclude infection, progression, and other causes; severe or rapidly worsening symptoms require urgent clinical assessment. Management and steroid regimens must be individualized by the treating team.

Radiation Dermatitis

Assess erythema, dry or moist desquamation, edema, bleeding, ulceration, and necrosis within the treated field.

Skin

CTCAE v5.0

Grade 1

Mild

Grading features

Faint erythema or dry desquamation; mild tightness or pruritus may occur.

Management considerations

Use gentle cleansing, fragrance-free moisturizers, and barrier products on intact skin; reduce friction and adhesive trauma.
A clinician may use a topical corticosteroid on intact inflamed skin according to the site-specific pathway.

CTCAE v5.0

Grade 2

Moderate

Grading features

Moderate to brisk erythema, patchy moist desquamation confined to skin folds or creases, or moderate edema.

Management considerations

Review skin-care technique and pain; use non-adherent dressings or hydrogel for moist areas as appropriate.
Keep topical corticosteroids to intact skin. Check for secondary infection if exudate, increasing pain, or fever develops.

CTCAE v5.0

Grade 3

Severe

Grading features

Moist desquamation outside skin folds; bleeding may occur with minor trauma or friction.

Management considerations

Arrange prompt wound-care or radiation-oncology assessment; use gentle cleansing and absorbent, non-adherent dressings.
Consider silver sulfadiazine only when prescribed under the local wound-care protocol; check allergy and site-specific precautions.

CTCAE v5.0

Grade 4

Life-threatening

Grading features

Life-threatening consequences, including full-thickness dermal ulceration or necrosis, spontaneous bleeding, or need for skin grafting.

Management considerations

Urgent specialist assessment; evaluate bleeding, infection, tissue viability, and need for hospital or surgical care.
Provide analgesia and wound care with a specialist-directed plan; use topical antimicrobials only when clinically indicated.

Radiation Pneumonitis

Distinguish asymptomatic radiographic change from symptomatic pneumonitis; exclude infection, embolism, progression, and other causes.

Thorax

CTCAE v5.0

Grade 1

Mild

Grading features

Asymptomatic; imaging or clinical observations only; intervention is not indicated.

Management considerations

Review symptoms, oxygen saturation, treatment timing, and imaging; monitor clinically and radiographically as indicated.
Do not start systemic corticosteroids for imaging changes alone unless another indication is established.

CTCAE v5.0

Grade 2

Moderate

Grading features

Symptomatic; medical intervention is indicated and instrumental activities may be limited.

Management considerations

Assess oxygenation and investigate competing diagnoses before attributing symptoms to radiation.
For clinically diagnosed symptomatic pneumonitis, a clinician may use prednisone about 1 mg/kg/day followed by an individualized 6-8 week taper; reassess response and relapse.
Give supplemental oxygen when hypoxemia or the patient’s clinical status indicates it.

CTCAE v5.0

Grade 3

Severe

Grading features

Severe symptoms limiting self-care activities; oxygen is indicated.

Management considerations

Urgent hospital-level assessment, oxygen and respiratory monitoring; involve pulmonology and radiation oncology.
Systemic corticosteroids are generally used after infection and other urgent causes have been evaluated; taper under close clinical supervision.

CTCAE v5.0

Grade 4

Life-threatening

Grading features

Life-threatening respiratory compromise requiring urgent intervention, such as ventilatory support.

Management considerations

Emergency or intensive-care management with airway and oxygenation support.
Urgently evaluate infection, pulmonary embolism, and other causes while specialists direct corticosteroids and additional treatment.

Radiation Esophagitis

Grade dysphagia, odynophagia, oral intake, hydration, and functional impact; consider infection, reflux, and obstruction.

Esophagus

CTCAE v5.0

Grade 1

Mild

Grading features

Asymptomatic or mild symptoms; intervention is not indicated.

Management considerations

Encourage fluids and soft, moist foods; avoid foods or temperatures that trigger pain.
Monitor swallowing, weight, and oral intake during treatment.

CTCAE v5.0

Grade 2

Moderate

Grading features

Symptomatic with altered eating or swallowing; oral supplements may be indicated.

Management considerations

Use small, frequent, soft meals and oral nutritional supplements; dietitian review is appropriate if intake declines.
Provide clinician-selected analgesia or mucosal protectants; assess for candidiasis, reflux, dehydration, and weight loss.

CTCAE v5.0

Grade 3

Severe

Grading features

Severely altered eating or swallowing; tube feeding, parenteral nutrition, or hospitalization may be indicated.

Management considerations

Urgent swallowing, nutrition, and hydration assessment; consider enteral support when oral intake is inadequate.
Treat identified infection and control pain; evaluate severe or progressive symptoms for stricture or other complications.

CTCAE v5.0

Grade 4

Life-threatening

Grading features

Life-threatening consequences requiring urgent intervention.

Management considerations

Urgent hospital and specialist evaluation for inability to maintain airway or hydration, bleeding, perforation, or obstruction.
Stabilize nutrition and fluids and treat the identified complication with gastroenterology and radiation-oncology input.

Oral Mucositis

Assess mucosal ulceration, pain, oral intake, hydration, and infection risk; document functional impact.

Oral cavity

CTCAE v5.0

Grade 1

Mild

Grading features

Asymptomatic or mild symptoms; intervention is not indicated.

Management considerations

Maintain gentle oral hygiene and bland saline or sodium-bicarbonate rinses; avoid tobacco, alcohol, and irritating foods.
Review hydration and oral-care technique at treatment visits.

CTCAE v5.0

Grade 2

Moderate

Grading features

Moderate pain or ulceration that does not interfere with oral intake; a modified diet may be indicated.

Management considerations

Use soft, moist foods and frequent fluids; consider topical mucosal protectants and clinician-selected analgesic suspensions.
“Magic mouthwash” formulations vary and are not standardized; prescribe only a locally approved formulation and assess for candidiasis or HSV when suspected.

CTCAE v5.0

Grade 3

Severe

Grading features

Severe pain interfering with oral intake.

Management considerations

Provide adequate systemic analgesia and urgent nutrition and hydration assessment; consider enteral support if intake is insufficient.
Examine for infection, bleeding, or superimposed causes and involve oral medicine or supportive-care specialists.

CTCAE v5.0

Grade 4

Life-threatening

Grading features

Life-threatening consequences requiring urgent intervention.

Management considerations

Urgent hospital assessment for airway compromise, uncontrolled bleeding, sepsis, or inability to maintain hydration.
Stabilize airway, infection, pain, fluids, and nutrition with multidisciplinary care.

Radiation Proctitis

Track urgency, frequency, tenesmus, pain, mucus, and rectal bleeding; distinguish acute toxicity from late injury.

Pelvis

CTCAE v5.0

Grade 1

Mild

Grading features

Mild symptoms or clinical observations only; intervention is not indicated.

Management considerations

Review stool pattern, hydration, and diet; monitor bleeding and symptom trajectory.
Exclude infection and medication-related causes when symptoms are new or atypical.

CTCAE v5.0

Grade 2

Moderate

Grading features

Moderate symptoms requiring medical intervention and potentially limiting instrumental activities.

Management considerations

Hydration and symptom-directed bowel care; a clinician may consider an antispasmodic for cramping after assessment.
For selected patients, topical corticosteroid or short-chain fatty-acid enemas may be considered by a specialist; evidence and suitability vary by setting.

CTCAE v5.0

Grade 3

Severe

Grading features

Severe symptoms limiting self-care or requiring hospitalization; clinically significant bleeding may occur.

Management considerations

Prompt gastroenterology or radiation-oncology assessment; check blood count and hemodynamic status when bleeding is significant.
Provide fluids, analgesia, and targeted treatment after evaluating infection, ulceration, and other causes; consider endoscopy when indicated.

CTCAE v5.0

Grade 4

Life-threatening

Grading features

Life-threatening consequences requiring urgent intervention.

Management considerations

Emergency hospital care for major hemorrhage, hemodynamic instability, perforation, or sepsis.
Resuscitation and urgent endoscopic, interventional, or surgical management as directed by specialists.

Radiation Cystitis

Assess urgency, frequency, dysuria, suprapubic discomfort, hematuria, retention, and hydration; exclude urinary infection.

Pelvis

CTCAE v5.0

Grade 1

Mild

Grading features

Mild symptoms or observations only; intervention is not indicated.

Management considerations

Encourage appropriate hydration and monitor urinary symptoms.
Obtain urinalysis or culture when clinically indicated; do not assume new urinary symptoms are radiation-related.

CTCAE v5.0

Grade 2

Moderate

Grading features

Moderate symptoms requiring medical intervention; catheterization is not indicated.

Management considerations

Exclude infection and retention; provide hydration and symptom-directed care.
A clinician may consider an antispasmodic for urgency or bladder spasm after reviewing contraindications and other causes.

CTCAE v5.0

Grade 3

Severe

Grading features

Severe symptoms; catheterization, transfusion, procedural intervention, or hospitalization may be indicated.

Management considerations

Urgent assessment for gross hematuria, clots, retention, anemia, or renal impairment; involve urology.
Monitor blood count and renal function as appropriate; bladder irrigation or other intervention requires specialist direction.

CTCAE v5.0

Grade 4

Life-threatening

Grading features

Life-threatening consequences requiring urgent intervention.

Management considerations

Emergency urology and hospital care for hemodynamic compromise, uncontrolled hemorrhage, or obstructive clot retention.
Stabilize circulation and urinary drainage; treat the underlying complication under specialist supervision.

Radiation-Induced Xerostomia

Assess dry or thick saliva, oral intake, salivary flow, dental health, and impact on speaking, chewing, and swallowing.

Salivary glands

CTCAE v5.0

Grade 1

Mild

Grading features

Symptomatic dry or thick saliva without significant dietary alteration; unstimulated saliva may remain above 0.2 mL/min.

Management considerations

Offer frequent sips of water, humidification, sugar-free gum or lozenges, and saliva substitutes or oral lubricants.
Start preventive dental care: fluoride, regular dental review, and meticulous oral hygiene.

CTCAE v5.0

Grade 2

Moderate

Grading features

Moderate symptoms with oral intake changes, such as frequent water or lubricants or a soft, moist diet; unstimulated saliva may be 0.1-0.2 mL/min.

Management considerations

Continue saliva substitutes, hydration, and dental prevention; adapt food texture and moisture to maintain intake.
Consider pilocarpine or another cholinergic agonist when residual gland function is likely and contraindications have been reviewed.

CTCAE v5.0

Grade 3

Severe

Grading features

Inability to maintain adequate oral alimentation; tube feeding or parenteral nutrition may be indicated; unstimulated saliva may be below 0.1 mL/min.

Management considerations

Arrange urgent nutrition, hydration, and dental assessment; provide enteral support if oral intake is inadequate.
Review candidiasis, dental caries, oral pain, and swallowing function; cholinergic treatment requires individualized medical review.

CTCAE v5.0

Grade 4

Not defined

Grading features

CTCAE v5.0 does not define a Grade 4 category for the Dry Mouth term. Record severe complications under the applicable CTCAE event.

Management considerations

If there is an acute threat to hydration, nutrition, airway, or safety, arrange urgent assessment and manage the complication directly.
Do not assign a CTCAE Grade 4 to xerostomia itself when the grading term does not define one.

Reference framework

Management summaries are not a substitute for the complete grading criteria, current evidence, or institution-approved pathways. Evidence for selected topical and enema therapies varies; confirm suitability with the relevant specialist.

NCI CTCAE v5.0 MASCC / ISOO mucositis guidance ASTRO practice resources