Radiation tissue injury

Radiotherapy can damage healthy tissue months or years after treatment has finished. This is called late radiation tissue injury. Hyperbaric oxygen is used for some of these injuries internationally, but UK guidance and NHS commissioning are more restrictive. NICE says HBOT for osteoradionecrosis of the jaw should only be considered as a part of a clinical trial, while NHS England does not routinely commission it for soft tissue radiation damage after pelvic radiotherapy. Standard care from your oncology and specialist teams comes first.

This page is written for people living with late effects of radiotherapy, their families, and clinicians considering whether hyperbaric oxygen has any place alongside standard care.

When radiotherapy leaves lasting damage

Radiotherapy treats cancer by damaging cells in the area treated. Most side effects settle in the weeks after treatment ends. The NHS is clear, though, that some side effects only develop months or even years after treatment starts.

When healthy tissue in the treated area breaks down long after radiotherapy, doctors call it late radiation tissue injury. NHS England describes it as serious radiation-related complications that can develop months or years later, that can significantly reduce quality of life, and that can be life threatening.

New symptoms should not automatically be attributed to previous radiotherapy. Your clinical team may need to assess for recurrent or new cancer, infection, and other treatable causes.

It can affect different parts of the body depending on where the radiotherapy was given:

The bowel and rectum after pelvic radiotherapy, causing bleeding, urgency, pain or diarrhoea, often called radiation proctitis
The bladder after pelvic radiotherapy, causing bleeding and pain, often called radiation cystitis
The jaw bone after head and neck radiotherapy, where bone dies and is exposed, called osteoradionecrosis
Skin and soft tissue in any treated area, which can break down or fail to heal after surgery or dental work

For the person living with it the timing is often the hardest part. The cancer treatment is over, and a new problem has appeared from it. The most useful first question is which tissue is affected and how badly, because that decides what can help.

What treatment usually involves

Care is led by the oncology team and the specialists for the part of the body affected: gastroenterology for the bowel, urology for the bladder, oral and maxillofacial surgery for the jaw, plastic surgery or a wound service for skin and soft tissue.

NHS England describes standard treatment as managing symptoms and, where needed, surgery to remove or repair the affected area. For osteoradionecrosis, NICE recommends considering surgery to remove dead bone and to establish soft tissue coverage.

For people whose condition does not respond to standard treatment, the best approach remains uncertain. HBOT has been studied as a possible additional treatment, but the evidence differs by the tissue affected and is not conclusive.
Standard care comes first. HBOT does not replace oncology, surgery, urology, gastroenterology, wound care, or other established treatment. If considered, it is an adjunct discussed with the team already responsible for your care.

What UK guidance says

NICE guideline NG36 says HBOT or medical management for osteoradionecrosis should only be considered as part of a clinical trial. NICE also recommends considering surgery to remove necrotic bone and establish soft-tissue coverage. NG36 addresses osteoradionecrosis in the context of upper aerodigestive tract cancer; it does not endorse HBOT for radiation damage to the bowel, bladder, or other soft tissues.
NHS England’s clinical commissioning policy for soft-tissue radiation damage after pelvic irradiation took effect in April 2019. It concluded that the evidence was insufficient to make HBOT routinely available for that specific condition.
NHS England’s current national specialised HBOT service specification provides for decompression illness and gas embolism. It explicitly lists soft-tissue radiation damage following pelvic irradiation among indications that are not routinely commissioned. This does not mean that every form of late radiation injury was separately assessed in the pelvic policy, or that exceptional NHS funding is impossible.
That is the current UK position and Heal & Go₂ works within it. We would rather set it out plainly than leave you to find it elsewhere.

How the international picture differs

International professional recommendations differ from the current UK guidance and commissioning position.
The European Committee for Hyperbaric Medicine, at its 2016 consensus conference, recommends HBOT for osteoradionecrosis of the jaw, for preventing osteoradionecrosis after dental extraction in irradiated jaws, for bleeding radiation cystitis and for radiation proctitis. It suggests it for osteoradionecrosis of other bones and for soft tissue radiation damage elsewhere, particularly in the head and neck, and describes use for radiation damage to the larynx or the central nervous system as optional. Most of these recommendations rest on what it grades as level B or level C evidence.

The Undersea and Hyperbaric Medical Society recognises delayed radiation injury, including soft-tissue and bony necrosis, as an accepted HBOT indication. This professional position does not change NICE guidance or NHS England commissioning.

Where it is used routinely

In the United States, Medicare covers HBOT for osteoradionecrosis and soft-tissue radionecrosis as an adjunct to conventional treatment. This is a coverage decision in a different health system and does not alter UK guidance or commissioning.
UK hyperbaric centres have participated in research on late radiation injury, including the sham-controlled HOT2 trial. Outside research, HBOT for late radiation injury is not a routinely commissioned indication under NHS England’s national specialised HBOT service.

Where the evidence shows possible benefit

The 2023 Cochrane review included 18 studies with 1,071 participants. It concluded that selected people with late radiation injury may benefit, but more research is needed to identify who responds and when treatment is best given. Certainty and results differ by outcome and the site of injury.
An earlier sham-controlled trial in radiation proctitis (Clarke and colleagues, 2008; 150 participants in NHS England’s review) reported better short-term improvement with HBOT than sham treatment. NHS England noted that the clinical importance of the difference was uncertain and that comparative longer-term results were limited.

Where the evidence does not support use

The UK HOT2 trial, published in 2016, enrolled 84 people with persistent bowel symptoms after pelvic radiotherapy and compared HBOT with sham treatment. It did not find a clinically relevant benefit for chronic gastrointestinal symptoms, including rectal bleeding. This conflicts with the earlier positive proctitis trial; the studies differed in their patients, measures and timing of assessment.
NHS England judged the sham-controlled evidence for pelvic soft-tissue radiation damage to be inconsistent and found no superiority over alternative treatment in two small comparative studies. Its policy therefore does not routinely commission HBOT for this indication.
HBOT can cause adverse effects. The Cochrane review reported reduced visual acuity and ear barotrauma; the ear-risk comparison depended on whether the control group underwent sham pressurisation. Individual risks and contraindications require assessment before treatment.
Evidence is particularly limited for radiation damage in some other tissues. The European consensus describes HBOT for laryngeal or central nervous system radiation injury as optional. We cannot infer a reliable benefit for an individual patient from an international indication list alone.

How we assess whether treatment is appropriate

We do not think everyone with late radiation injury should have hyperbaric oxygen, and we do not think everyone should be ruled out. Both positions are too simple.
Standard care comes first. Your oncology team and the specialists for the affected area stay in charge of your care. Nothing on this page is a reason to change, pause or delay anything they have recommended. If we treat you we work alongside them, and we write to them.
The UK position is part of the assessment. We will explain NICE’s trial-only recommendation for osteoradionecrosis and the conflicting bowel evidence, including HOT2’s negative result. A private consultation does not change those recommendations.
Not everyone can have HBOT safely. We assess contraindications, possible adverse effects and any relevant cancer treatment. See our safety page for general information; an individual clinical assessment determines whether treatment is suitable.
Before considering HBOT, the relevant specialist team should establish the diagnosis of late radiation tissue injury and consider recurrent or active malignancy and other treatable causes where clinically appropriate. We normally require information from the oncology or relevant specialist team. The Medical Director reviews the diagnosis, prior treatment, evidence and safety within our clinical governance process, then explains whether HBOT has any plausible adjunctive role. We discuss uncertainties, risks, alternatives and costs before any decision.
HBOT is not appropriate for every patient or every form of radiation injury. Some people may benefit from specialist assessment. If we do not think it is appropriate or likely to help, we will say so.

Common questions

Is hyperbaric oxygen available on the NHS for radiation damage?

Not routinely. NHS England's national specialised HBOT service provides for decompression illness and gas embolism, and lists soft-tissue radiation damage following pelvic irradiation among indications that are not routinely commissioned. Its policy, which took effect in April 2019, concluded that the evidence was insufficient to make HBOT routinely available for that specific condition. This does not mean that every form of late radiation injury was separately assessed, or that exceptional NHS funding is impossible. Ask your NHS specialist whether any research or exceptional pathway applies to you.

Can it help bowel problems after pelvic radiotherapy?

The UK HOT2 trial compared HBOT with sham treatment in 84 people with persistent bowel symptoms after pelvic radiotherapy and did not find a clinically relevant benefit, including for rectal bleeding. An earlier sham-controlled trial in radiation proctitis reported better short-term improvement with HBOT; the studies differed in their patients, measures and timing of assessment. NHS England judged this evidence inconsistent and does not routinely commission HBOT for it. New bowel symptoms should be assessed by your gastroenterology or oncology team for other causes first, and they lead your care.

Can it help osteoradionecrosis of the jaw?

NICE guideline NG36, on cancer of the upper aerodigestive tract, says HBOT for osteoradionecrosis should only be considered as part of a clinical trial, and recommends considering surgery to remove dead bone and establish soft-tissue coverage. The European Committee for Hyperbaric Medicine recommends HBOT for osteoradionecrosis of the jaw; that professional position does not change NICE guidance. Your maxillofacial team leads this decision, and we would explain NICE's trial-only recommendation before any assessment.

Does it replace the treatment my oncology team has planned?

No. HBOT does not replace oncology, surgery, urology, gastroenterology, wound care or other established treatment. If it is considered, it is an adjunct discussed with the team already responsible for your care. If we treat you, we work alongside them and write to them.

Is it safe?

HBOT can cause adverse effects. The Cochrane review reported reduced visual acuity and ear barotrauma in people treated for radiation injury, and some people cannot receive HBOT safely. We assess contraindications, possible adverse effects and any relevant cancer treatment before any decision. See our safety page for more detail.

Clinical and advertising approval: Approved 30 September 2026 · Dr Anil Dasineni (own revision)
Reviewed by: Dr Anil Dasineni, MBBS, DNB (Emergency Medicine), MRCEM. Registered with the General Medical Council with a licence to practise.
Last reviewed: 1 October 2026
Next review due: 24 September 2027
Clinical tier: Tier 1

Sources (10)

www.nice.org.uk/guidance/ng36, www.england.nhs.uk/wp-content/uploads/2018/11/Hyperbaric-oxygen-therapy-services-all-ages-Service-specification-January-2025.pdf, www.england.nhs.uk/commissioning/spec-services/npc-crg/group-d/hyperbaric-oxygen-therapy/, www.england.nhs.uk/wp-content/uploads/2018/07/hbot-for-soft-tissue-radiation-damage-v2.pdf, www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005005.pub5/full, pubmed.ncbi.nlm.nih.gov/26703894/, www.echm.org/documents/DHM%202017-Mathieu%20D-Tenth%20European%20Consensus%20Conference%20on%20Hyperbaric%20Medicine.pdf, uhms.org/resources/featured-resources/hbo-indications.html, www.nhs.uk/conditions/radiotherapy/side-effects/, www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=12

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