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For radiotherapy to the head or neck you wear a close-fitting plastic mesh mask, moulded to your face while it is warm and clipped to the table, so you are in exactly the same place every day. About a quarter of people feel anxious in the mask. Tell the team early: they can explain each step, give breaks, let you play music, and in some departments use a mask with the face left open.
The ESTRO ACROP guideline (2017) sets out the radiation therapist's procedure: a full explanation beforehand, including the mask's temperature and how to signal for help; removal of dentures, hearing aids and piercings in the field; a straight, comfortable and reproducible position with every device indexed to the couch; any mouth bite or stent in place before moulding; a mask of three or more fixation points (five points when the low neck is treated, or a shoulder retractor with a three-point mask); a check of the material's temperature before it touches the skin; moulding within one to two minutes and hardening for five to fifteen; reassurance during hardening; removal and refitting before the CT scan; and labelling of the mask. It advises against cutting out the mask except for a bite block or tracheostomy.
Mask anxiety affected 26% of 100 consecutive patients in one Australian cohort and 27.3% of 410 in a validation study of a four-item screen (R-MAQ); in a prospective cohort it fell during treatment in 72% of those affected. Both Australian studies recommend routine screening, which no guideline yet requires. One randomised trial (216 patients, India, 2025) found music with guided relaxation in the first five sessions lowered mask anxiety. The OPEN phase 3 trial (230 non-claustrophobic patients, 2026) found open-face masks with surface-guided radiotherapy as accurate as a closed five-point mask and better tolerated, which departs from the ESTRO advice against cutting the mask; claustrophobic patients were excluded.
Why: Knowing what will happen, and what it will feel like, makes the appointment less frightening.
“A full and detailed explanation of the procedure should be given to the patient by an RTT.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: Being able to stop things at any moment gives back a sense of control.
“Other aspects related to both the safety and efficacy of the procedure should be discussed with the patient including the likely mask temperature, and how the patient can alert the RTTs if they are having difficulty during the procedure.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: About one person in four finds the mask distressing, and staff do not always notice.
“Due to its high prevalence and variable patterns over time, it is recommended that routine screening for mask anxiety be implemented as standard care throughout the course of RT for HNC.”
Journal of Medical Radiation Sciences (Nixon et al.) 2019 · Recommendation of a prospective cohort study (35 patients); not a guideline
Why: Anything worn when the mask is made must be the same every day, and metal can disturb the scan and the dose.
“Any dentures, hearing aids, toupees, earrings and all kinds of piercings in the treated area including tongue piercings must also be removed.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: The mask can only hold a position that can be repeated exactly each day.
“All immobilisation devices must be indexed and fixed to the couch, to minimise rotational and translational errors.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: The lower neck and shoulders move unless they are held too.
“If treating the low neck, a 5-point mask is recommended. If a 3-point mask is used, a device to maintain shoulder position, such as a retractor, is mandatory.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: The patient must be able to breathe freely throughout.
“It may be necessary to cover the hair with cotton-type material and to ensure that the patient’s airway is not compromised during the procedure.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: The plastic is softened in hot water or an oven and could burn if applied too hot.
“The temperature of the material must be checked before placing on the patient’s skin to avoid burns.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: The mask takes several minutes to set, and calm breathing helps people relax.
“The patient should be supported and reassured by the RTTs during this time period. Motivating and supporting patients to use abdominal breathing will help them to relax during the whole procedure.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: A mask that fits at the scan will fit at treatment, and the break helps.
“It is recommended that the mask be removed and refitted prior to commencement of CT scanning to ensure that the fit is correct and that the immobilisation provided by the mask is adequate.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: Each mask belongs to one person and must be used with the same supports every day.
“For safety reasons, the patient name, type of neck rest and wedges used should always be documented on the patient mask, preferably using a method that can identify the mask in the oncology information system.”
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Guideline (ungraded)
Why: In one randomised trial, music with guided relaxation lowered anxiety in the mask within five sessions.
“At the end of five RT sessions, the intervention group showed a statistically significant reduction in mask anxiety scores [median (IQR): 2 (2)] compared to the control group [median (IQR): 6 (1)], with p < 0.001.”
Supportive Care in Cancer 2025 · Single randomised trial (216 patients)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Make the mask by the ESTRO ACROP procedure (2017): explanation and an agreed signal, a straight reproducible position with every device indexed, any bite block in place first, three or more fixation points and five for the low neck, a temperature check before the material touches the skin, reassurance while it sets, and a refit before the CT. Screen for mask anxiety early (recommended by the Australian cohort studies and supported by a validated four-item screen, R-MAQ, though no guideline yet requires it) and offer support, including music with guided relaxation (one randomised trial). Where surface-guided radiotherapy is available, an open-face mask is as accurate as a closed five-point mask and better tolerated (OPEN phase 3 randomised trial, 2026); this departs from ESTRO's 2017 advice against cutting out the mask, written before such trials existed.
ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017 · Journal of Medical Radiation Sciences (Nixon et al.) 2018 · Journal of Medical Radiation Sciences (Nixon et al.) 2019 · Psycho-Oncology 2025 · Supportive Care in Cancer 2025 · Radiotherapy and Oncology (Nicholson et al.) 2026
Where it differs: The mask leaves the eyes, nose and mouth uncovered and a surface camera tracks the exposed face, neck and upper chest from set-up through treatment. ESTRO ACROP (2017) advises against cutting out the mask except for a bite block or tracheostomy.
Evidence: OPEN phase 3 trial: 230 non-claustrophobic patients randomised to a closed five-point mask or an open three- or five-point mask with surface guidance; set-up accuracy equivalent (larger longitudinal shifts with the closed mask, P < 0.001) and tolerability, experience and distress better with both open masks (p < 0.01). An earlier open-face mask study treated five claustrophobic patients who could only tolerate the open mask.
Radiotherapy and Oncology (Nicholson et al.) 2026 · MethodsX 2026 · Journal of Applied Clinical Medical Physics (Li et al.) 2013 · ESTRO ACROP (Leech et al., Technical Innovations and Patient Support in Radiation Oncology) 2017
Where it differs: A four-item questionnaire given before planning identifies people at risk of an anxious response to the mask, rather than relying on staff noticing or a single distress question.
Evidence: Validation in 410 patients: area under the ROC curve 0.78, with 27.3% showing an anxious response at planning; comparable or better than a general claustrophobia questionnaire. No trial yet shows that screening changes outcomes.
Radiotherapy to the head usually means a moulded plastic mask clipped to the table over the whole face. In a randomised comparison in 29 people with brain tumours, a mask with the face cut out caused much less discomfort and anxiety with the same accuracy, and 27 of them preferred it.
About a quarter of people having radiotherapy for head and neck cancer say the mask makes them anxious, and radiographers do not reliably notice who. A randomised trial of 208 people in India found that music and a guided relaxation exercise during the first five sessions lowered mask anxiety scores.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| A quarter of patients report mask anxiety “In phase one, 26% of participants self‐identified as being anxious about the use of a thermoplastic mask.” | Mixed-methods cohort (100 patients) | Journal of Medical Radiation Sciences (Nixon et al.) 2018 |
| Mask anxiety usually eases during treatment “In 72% of participants, the level of initial distress was found to reduce over time.” | Prospective cohort (35 patients) | Journal of Medical Radiation Sciences (Nixon et al.) 2019 |
| Open masks with surface guidance give equivalent accuracy and a better experience “At treatment completion patient experience metrics, including tolerability, overall experience and distress, were significantly more favourable for both open-mask cohorts compared to closed masks (p < 0.01).” | Phase 3 randomised trial (230 patients) | Radiotherapy and Oncology (Nicholson et al.) 2026 |
| A brief screen predicts an anxious response at planning “Of the 410 participants (mean age 62), 27.3% presented an anxious response to the immobilization mask during planning exams.” | Validation study (410 patients) | Psycho-Oncology 2025 |
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