Ingrid Hein

May 03, 2016

For cancer patients undergoing alopecia-inducing chemotherapy, scalp cooling to reduce hair loss is safe, according to new research.

"This is a treatment that women going into chemotherapy treatment need to know about," said Mikel Ross, RN, BSN, from the Memorial Sloan Kettering Cancer Center in New York City. "Patients are asking for this."

The technique, which has been used in Europe since the 1970s, was only approved by the US Food and Drug Administration in December 2015, but doctors and nurses in the United States have yet to embrace it.

They are holding on to a 40-year-old belief that the treatment is unsafe and that it can result in scalp metastases, Ross told Medscape Medical News. "That has to change."

The issue of hair loss during chemotherapy should not be taken lightly. "More than 75% of women see hair loss as the most feared side effect of chemotherapy," he said, citing one study in which 10% of patients said they would consider refusing chemotherapy or consider a less effective treatment to avoid hair loss.

Although scalp cooling appears to be safe, the 50% success rate and the discomfort make women think twice about using it — not to mention cost. Still, doctors and nurses need to pass on better information so that patients can make an informed decision, he explained.

Ross presented an examination of 40 systematic reviews, comparative trials, and publications on scalp cooling at the Oncology Nursing Society 2016 Annual Congress in San Antonio.

An analysis of two Dutch studies — one a scalp cooling registry of 1411 patients (Acta Oncol. 2012;51:497-504) and the other a systemic review of 50,000 breast cancer patients (Breast. 2013;22:1001-1004) — concluded that scalp metastases are rare. This is the most common safety issue cited by doctors about the treatment, Ross reported, but the research shows an incidence rate of scalp metastases of about 1.0% in patients who use cooling and in those who do not.

We need to catch up on the research and change our thinking.

In fact, in a review of 49,711 patients, 0.04% to 1.00% who were treated with cooling developed scalp metastases, as did 0.30% to 3.00% of those who were not treated with cooling (Breast. 2013;22:1001-1004).

In addition, in a retrospective review of 640 patients from Quebec, Canada, rates of scalp metastases were similar whether or not scalp cooling was used (1.1% vs 1.2%) (Breast Cancer Res Treat. 2009;118:547-552).

"We need to catch up on the research and change our thinking," Ross said.

Success with the technique — defined as a woman not having to wear a wig or head covering at her final chemotherapy treatment — ranges from 10% to 100% (Breast. 2011;20[Suppl 1]:S80).

In general, however, "the research shows that 50% of women reduce their hair loss and don't feel they need to cover their head on their last day of chemotherapy," Ross reported.

Variability in success rates depends on a host of determinants, including chemotherapy type and dose, cooling system used, and patient-specific variables. And metabolic differences and differences in hair quality might also have an effect.

"There are no core data on textured vs straight hair, or whether curled hair does better," Ross said. "But we found that if you cool, you will keep more than if you don't; the rest is a gamble."

It's a viable option, and most important, "the data suggest that it's safe," he added.

Cost is the fly in the ointment; it's not covered by Medicare because it's considered cosmetic.

Still, the treatment is not for everyone. One version of scalp cooling — cold cap therapy — requires that the caps be frozen in dry ice or a freezer and be changed every 20 to 30 minutes. It is recommended that the caps be worn 1 to 2 hours before and about 3 hours after chemotherapy treatment. That means a 2- to 3-hour chemotherapy session can turn into a 6- to 8-hour sitting requiring about 22 caps.

In contrast, cooling systems such as Paxman and DigniCap use a refrigeration machine to continually cool the cap while it is being worn by the patient, eliminating the need for cap changing.

It's cold, it's uncomfortable, it's boring, and can make a chemotherapy session very long, Ross pointed out. However, overall tolerability is high.

"Scalp cooling caps are available now in the United States, and machines will be available in the next year or so," he said.

Currently, patients can rent cold caps for about $580 a month, but they also need a freezer or dry ice at the hospital and someone to help with the frequent cap changes. "Cost is the fly in the ointment; it's not covered by Medicare because it's considered cosmetic. But I think that's likely to change," Ross said.

In their review of treatment discontinuation, Ross and his colleagues found that 3% of patients discontinued scalp cooling treatment in two studies (Acta Oncol. 2012;51:497-504 and J Clin Oncol. 2015;33[suppl];abstr 9518), but in another study, the discontinuation rate was 12.6% (Support Care Cancer. 2013;21:2565-2573).

"I recommend that patients whose treatment includes chemotherapy discuss the issues with their oncologist," said Ted Gansler, MD, director of medical content at the American Cancer Society.

Patients should ask if the medications they are prescribed will likely cause hair loss, how soon hair will grow back after treatment, whether their type of cancer often spreads to the scalp, and whether a cooling cap would increase that risk, he told Medscape Medical News.

Many clinicians worry that a few cancer cells might have broken loose from the main tumor, entered the bloodstream, and ended up in the scalp. "Even when some cancers appear to have been completely removed by surgery, chemotherapy is often given after surgery to kill the cells in these microscopic metastases so they don't form new tumors in other parts of the body," he explained.

Scalp cooling is now being used at Memorial Sloan Kettering, Ross reported. To date, 30 patients have been treated with the caps. But he and his team agree that the treatment is not for everyone, and caution against scalp cooling for patients with blood-related cancers like leukemia and for patients with diseases that cause extreme sensitivity to coldness.

It makes chemo a good medicine instead of a bad medicine.

Cap cooling might not be for everyone, but it does more than just help retain hair, said Nancy Marshall, from the Rapunzel Project in Minneapolis.

"It makes chemo a good medicine instead of a bad medicine because when you use scalp cooling, chemo can fight the disease and not punish the patient," she said.

Marshall, a breast cancer survivor herself, cofounded the project with Shirley Billigmeier after being Billigmeier's "assistant cap changer" during her chemotherapy sessions. The Rapunzel Project helps educate women about scalp cooling and raises funds to get freezers in chemotherapy treatment centers. She said oncology nurses are their biggest allies in getting freezers into clinics, which in turn raises awareness. "They work closely with patients and really understand how important this is," Marshall said.

If you have heart problems, nobody has to know. If you lose your hair, everyone knows you have cancer.

She doesn't like the argument that it's all about vanity. "When you look in the mirror and feel better about yourself, that contributes to wellness," she pointed out.

Marshall said she hears two main reasons women feel strongly about keeping their hair. "Privacy is a huge driver. If you have heart problems, nobody has to know. If you lose your hair, everyone knows you have cancer," she said. And "we see a lot of young moms that don't want their kids to be scared, to see mommy looking sick. Ask a mother; it's worth almost any amount of discomfort to avoid that discomfort."

"Identity is also important," she added. "When you look in the mirror, you don't want to see a stranger looking back."

Mr Ross, Dr Gansler, and Ms Marshall have disclosed no relevant financial relationships.

Oncology Nursing Society (ONS) 2016 Annual Congress. Presented April 30, 2016.


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