The loss of my late aunt Millie to breast cancer was devastating; it was even harder to bear after learning that she was aware of the advancing breast tumors, but so afraid of chemotherapy that she delayed treatment until the cancer was too advanced. I do not know if it was the potential for hair loss that she feared most, however, 47% of female patients view alopecia as the most traumatic aspect of chemotherapy. Eight per cent would decline chemotherapy rather than lose their hair (1).
Scalp cooling is the most effective method of diminishing chemotherapy-induced hair loss. Two proposed mechanisms of action are: 1) vasoconstriction, thereby limiting the uptake of the chemotherapeutic agents; and 2) a reduction of metabolic activity that decreases the chemotherapeutic effect on the follicle. Importantly, cooling devices do not increase the risk of scalp metastases (2).
New cooling systems utilize tight-fitting caps connected to cooling machines that gradually cool the scalp. The cap remains in place during the chemotherapy and for about 90 minutes after cessation of therapy. The average total cost for scalp cooling is approximately $1500 to $3000 per patient, depending on the number of treatment cycles. As this is considered “cosmetic”, despite the detrimental effects on quality of life secondary to alopecia, the cost would most likely be borne by the patient (3).
Two trials on the effect of scalp cooling devices on alopecia in women on chemotherapy for breast cancer were published in JAMA this week. Nangia et al, in a randomized clinical trial of 182 women receiving chemotherapy (with a taxane, anthracycline, or both) who underwent scalp cooling were significantly more likely to have less than 50% hair loss compared to those with no scalp cooling (4). In a multicenter trial of 122 patients, hair loss of 50% or less was observed in 66.3% of patients in the scalp cooling group versus 0% of patients in the control group at 4 weeks after completing non-anthracycline-based adjuvant chemotherapy. As opposed to Nanglia’s study where there was, interestingly, no significant improvement in quality of life (QOL), 3 of 5 QOL measurements, including feeling less physically attractive, showed benefit for women who received scalp cooling (5). Both studies advocate further research to determine longer term outcomes and potential adverse effects.
As with other malignancies, it is hoped that breast cancer is discovered early enough to avoid chemotherapy, or that the development of targeted therapies will not result in as much alopecia as current chemotherapeutic protocols. For example, trastuzumab (Herceptin) does not appear to cause alopecia (6). Until such personalized protocols are standard therapy, we can better assist our patients in preserving their dignity through this arduous process. Let cool heads prevail!
- Trüeb RM. Chemotherapy-induced alopecia. Curr Opin Support Palliat Care. 2010; 4: 281-4.
- Young A, Arif A. The use of scalp cooling for chemotherapy-induced hair loss. Br J Nurs 2016; 25:S22, S24-7.
- Hershman DL. Scalp cooling to prevent chemotherapy-induced alopecia. The time has come. JAMA 2017; 317: 587-8.
- Nangia J, et al. Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: The SCALP randomized clinical trial. JAMA 2017; 317: 596-605.
- Rugo HS, et al. Association between use of a scalp cooling device and alopecia after chemotherapy for breast cancer. JAMA 2017; 317: 606-14.
- Kim DH, et al. Psoriasis induced by trastuzumab (Herceptin). Ann Dermatol 2013; 25: 229-31.