Effect of a Scalp Cooling Device on Alopecia in Women Undergoing Chemotherapy for Breast Cancer: The SCALP Randomized Clinical Trial

Cancer-Related Alopecia: From Etiologies to Global Management

Simple Summary

Although it does not represent a condition that threatens the life of patients, alopecia nevertheless has an essential impact on the quality of life of patients, particularly in terms of the psychological and social aspects. Indeed, while it has long been considered an acceptable side effect in the management of patients, the progressive emergence of a patient-centered approach coupled with a better knowledge of the pathophysiological processes involved has led to a better consideration of alopecia, both on the preventive and palliative sides. Thus, cancerous alopecia can be multifactorial: iatrogenic (in particular via conventional chemotherapy), induced by a vitamin/nutritional deficiency, or even caused by the disease itself. In this state-of-the-art review, we therefore cover alopecia in an exhaustive manner by considering the different mechanisms involved and their frequency as well as the various therapies offered.

Abstract

Alopecia represents a multifaceted challenge with distinct etiologies and consequences. Transposed to the world of oncology, different types of alopecia and molecular pathways have been characterized, allowing a better understanding of the underlying mechanisms. In patients with cancer, alopecia can be iatrogenic (i.e., due to conventional chemotherapies, endocrine therapies, targeted therapies, immunotherapies, radiotherapy and surgery) or a direct consequence of the disease itself (e.g., malnutrition, scalp metastases and paraneoplastic syndromes). Identification of the actual incriminated mechanism(s) is therefore essential in order to deliver appropriate supportive care, whether preventive or curative. On the preventive side, the last few years have seen the advent of the automated cooling cap, a prophylactic approach supported by several randomized clinical trials. On the curative side, although the treatments currently available are limited, several promising therapeutic approaches are under development. Appropriate alopecia management is essential, particularly regarding its psychological repercussions with significant consequences on the quality of life of patients and their family and with a potential impact on treatment compliance.

Tackling metastatic triple-negative breast cancer with sacituzumab govitecan

Introduction Metastatic triple-negative breast cancer (TNBC) is an aggressive cancer with poor survival that is difficult to treat due to a lack of targeted options. Conventional therapies targeting hormone receptors (HR) and human epidermal growth factor 2 (HER2) are ineffective and often chemotherapy is standard-of-care. Sacituzumab govitecan is an antibody drug conjugate (ADC) comprised of an active metabolite of irinotecan, SN-38, bound to a humanized monoclonal antibody targeting trophoblastic cell-surface antigen 2 (Trop-2). Trop-2 is highly expressed on the surface of TNBC cells, making it an attractive target. Areas covered We explore the mechanism, pharmacology, efficacy, safety, and tolerability of sacituzumab govitecan. A literature search was conducted via PubMed using keywords such as 'sacituzumab govitecan,' and 'metastatic TNBC.' Expert opinion Sacituzumab govitecan has promising survival benefits in patients with previously treated mTNBC based on data from the ASCENT trial. Common adverse effects were neutropenia, diarrhea, and nausea, however these effects were manageable with supportive care. Sacituzumab govitecan has shown promise in cancers outside of TNBC, such as urothelial and lung and is being evaluated in HR-positive breast cancers. It is likely we will see this therapy used in combination with other novel targeted agents as current clinical trials mature.

Identifying Barriers and Facilitators to Scalp Cooling Therapy Through a National Survey of the Awareness, Practice Patterns, and Attitudes of Oncologists

PURPOSE

Scalp cooling therapy (SCT) is the most effective method to reduce chemotherapy-induced alopecia (CIA), a highly distressing side effect of cancer treatment. Despite data supporting SCT efficacy and safety, SCT use in the United States is not widespread. Oncologists' interactions with scalp cooling were examined to identify facilitators and barriers to SCT implementation.

METHODS

A 33-question survey was distributed through the ASCO Research Survey Pool to a nationally representative, random sample of 600 oncology providers. Outcome measures included knowledge of SCT, frequency of initiating conversations about SCT with patients, degree of support, and barriers for SCT. Significance was defined as P < .001.

RESULTS

Of 155 (25.8%) responding providers, 62% of providers were in favor of SCT always or most of the time, but only 26% reported initiating discussions about SCT always or most of the time. Providers who treat breast cancer (P ≤ .0001), those who report being very familiar with SCT (P ≤ .0001), those who report having read SCT literature in the past 2 years (P ≤ .0001), and those who work at a facility with machine SCT (P ≤ .0001) were significantly more likely to initiate conversations with patients about SCT. Financial concerns (58%) were the primary reason for not recommending SCT use; efficacy (31%), staff or facility (24%), and safety (15%) concerns were also noted. Although safety concerns have decreased markedly over time, 14% of providers report patients who continue to express these concerns and 17% of providers see safety issues as barriers to supporting SCT.

CONCLUSION

Our findings suggest that oncology provider familiarity and experience with SCT lead to increased support for scalp cooling, which may ultimately result in greater availability and utilization of SCT when indicated.

PPARγ signaling protects hair follicle stem cells from chemotherapy-induced apoptosis and epithelial-mesenchymal transition

BACKGROUND

Permanent chemotherapy-induced alopecia (pCIA), for which preventive interventions remain limited, can manifest with scarring. While the underlying pathomechanisms of pCIA are unclear, depletion of epithelial hair follicle (HF) stem cells (eHFSCs) is likely to play a role.

OBJECTIVES

To explore the hypothesis that eHFSCs undergo pathological epithelial-mesenchymal transition (EMT) besides apoptosis in pCIA, thus explaining the scarring phenotype. Furthermore, we tested whether a PPARγ modulator can prevent pCIA-associated pathomechanisms.

METHODS

Organ-cultured human scalp HFs were treated with the cyclophosphamide metabolite, 4-hydroperoxycyclophosphamide (4-HC). Additionally, HFs were pre-treated with the agnostic PPARγ modulator, N-Acetyl-GED-0507-34-Levo (NAGED), which we had previously shown to promote K15 expression and antagonize EMT in eHFSCs.

RESULTS

In accordance with anticipated hair bulb cytotoxicity, dystrophy and catagen induction, 4-HC promoted apoptosis along with increased p53 expression, DNA damage and pathological EMT in keratin 15+ (K15) bulge eHFSCs, as evidenced by decreased E-cadherin expression and the appearance of fibronectin- and vimentin-positive cells in the bulge. Pre-treatment with NAGED protected from 4-HC-induced hair bulb cytotoxicity/dystrophy, and halted apoptosis, p53 up-regulation, and EMT in the bulge, thereby significantly preventing the depletion of K15+ human eHFSCs ex vivo.

CONCLUSIONS

A cyclophosphamide metabolite alone suffices to damage and deplete human scalp eHFSCs by promoting apoptosis, DNA damage, and EMT ex vivo. Therefore, pCIA-therapeutic strategies need to target these pathological processes. Our data introduce the stimulation of PPARγ signaling as a novel intervention strategy for the prevention of pCIA, given the ability of NAGED to prevent chemotherapy-induced eHFSCs damage ex vivo.

Effect of Scalp Cooling on the Pharmacokinetics of Paclitaxel

Simple Summary

This study investigated the correlation between scalp cooling used to prevent chemotherapy-induced alopecia and the pharmacokinetics of paclitaxel in female cancer patients with a solid tumor. In a prospective cohort study, 14 patients who were treated with weekly paclitaxel and scalp cooling were able to undergo pharmacokinetic sampling of paclitaxel during one cycle of treatment. In comparison to a control cohort of 24 patients treated with weekly paclitaxel without scalp cooling, our data showed that scalp cooling used concomitantly with one course of paclitaxel did not reduce or increase the clearance of paclitaxel. Therefore, it is unlikely that scalp cooling influences paclitaxel efficacy or toxicity. Finally, despite scalp cooling, half of the patients in our study developed a form of hair loss. Importantly, neither an association with difference in paclitaxel clearance nor change in hair loss was found.

Abstract

Chemotherapy-induced alopecia (CIA), a side effect with high impact, can be prevented by cooling the scalp during the administration of some cytotoxic drugs. However, the effects of this prolonged scalp cooling on the pharmacokinetics of chemotherapy have never been investigated. In this study, we compared the pharmacokinetics of the widely used chemotherapeutic agent paclitaxel (weekly dose of 80–100 mg/m²) in female patients with solid tumors using concomitant scalp cooling (n = 14) or not (n = 24). Blood samples were collected in all patients for pharmacokinetic analyses up to 6 h after one course of paclitaxel administration. The primary endpoint was the clearance (L/h) of paclitaxel. Paclitaxel clearance—expressed as relative difference in geometric means—was 6.8% (90% CI: −16.7% to 4.4%) lower when paclitaxel was administered with concomitant scalp cooling versus paclitaxel infusions without scalp cooling. Within the subgroup of patients using scalp cooling, paclitaxel clearance was not statistically significantly different between patients with CIA (alopecia grade 1 or 2) and those without CIA. Hence, scalp cooling did not negatively influence the clearance of paclitaxel treatment.

Scalp cooling for reducing alopecia in gynecology oncology patients treated with dose-dense chemotherapy: A pilot project

•

Scalp cooling may be of benefit to gynecology oncology patients.

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Cooling may prevent alopecia induced by Carboplatin and weekly Paclitaxel treatment.

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For Carboplatin with Paclitaxel every three weeks, alopecia is not prevented.

Objective

Determine the efficacy of scalp cooling for the prevention of chemotherapy-induced alopecia in gynecology oncology patients.

Methods

This prospective pilot study included patients diagnosed with a gynecological malignancy that received DigniCap™ scalp cooling. Patients were divided into two groups based on chemotherapy regimen: Carboplatin with area under the curve (AUC) 5–6 every three weeks and (1) conventional Paclitaxel 175 mg/m² every three weeks or (2) Paclitaxel 80 mg/m² weekly. A 1–10 visual analogue scale (1 no hair loss, 10 – complete hair loss) was used to assess degree of hair loss by patients themselves and by a certified dermatologist using photographs. Changes in quality of life and body image were measured using the European Organization for Research and Treatment of Cancer quality of life questionnaire version 3 (EORTC QLQ-C30) and the Body Image Scale (BIS) for cancer patients.

Results

Hair preservation occurred with use of a scalp cooling device for patients receiving weekly Paclitaxel (n = 20), but not conventional every three weeks Paclitaxel (n = 8). Ten of 15 patients (66.7%) in the dose-dense group lost less than 50% of their hair based on self-assessment and 14 of 16 (87.5%) based on dermatologist assessment. No patient in this group acquired a cranial prosthesis (wig). There was no difference between groups in terms of quality of life (QoL) and BIS scores.

Conclusion

Scalp cooling may allow for hair preservation in gynecology oncology patients receiving Carboplatin AUC 5–6 and weekly Paclitaxel 80 mg/m² combination chemotherapy.

[Alopecia and cancers: From basics to clinical practice]

Alopecia, although long considered an unavoidable consequence of cancer therapy, currently presents a multifaceted challenge. The knowledge of the physiology of the hair and consequently of the pathophysiology of alopecia has led to show that there is not one but several types of alopecia. Transposed to the world of oncology, different types of alopecia and subsequently molecular pathways have been characterized, allowing a better understanding of the underlying mechanisms. Thus, in patients with cancer, alopecia can be iatrogenic (chemotherapies, endocrine therapies, targeted therapies, immunotherapies, radiotherapy, surgery) or directly the consequence of the disease itself (malnutrition, scalp metastases, paraneoplastic syndromes). Knowledge of the incriminated mechanism(s) could thus make it possible to deploy an appropriate care component, whether on the preventive or curative sides or in terms of supportive care. These are particularly essential regarding the psychological repercussions caused by alopecia, with significant consequences on the quality of life of patients and with a potential impact on treatment compliance. On the preventive side, the last few years have seen the advent of the automated scalp cooling therapy, supported by several randomized clinical trials. On the curative side, several therapeutic proposals are currently deployed or under development in order to provide relevant treatments.

Treatment of Patients with Early Breast Cancer: Evidence, Controversies, Consensus: German Expert Opinions on the 17th International St. Gallen Consensus Conference

This year's 17th St. Gallen (SG) Consensus Conference on the Treatment of Patients with Early Breast Cancer (SG-BCC) with the title "Customizing local and systemic therapies for women with early breast cancer" focused on the challenge of targeting the treatment of early breast cancer more specifically to the individual disease situation of each patient. As in previous years, a German working group of leading breast cancer experts discussed the results of the international SG-BCC 2021 in the context of the German guideline. It is helpful to compare the SG recommendations with the recently updated treatment recommendations of the Breast Commission of the German Working Group on Gynaecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie e. V., AGO) and the S3 guideline because the SG-BCC panel comprised experts from different countries, which is why country-specific aspects can be incorporated into the SG recommendations. The German treatment recommendations of the AGO and the S3 guideline are based on current evidence. Nevertheless, any therapeutic decision must always undergo a risk-benefit analysis for the specific situation and to be discussed with the patient.

Anti-cancer therapy made easier: a 25-year update

In 1993, the Internal Medicine Journal published ‘Chemotherapy made easier’, outlining developments in supportive care of patients undergoing chemotherapy. This described the contemporary state of anti‐emetics, colony stimulating factors, cardiac toxicity, neurotoxicity, development of drug analogues and venous access devices. Twenty‐five years later, we update the measures that improve the tolerability of the plethora of new anti‐cancer therapies, which have extended well beyond traditional chemotherapy agents to include immunotherapy and targeted therapies. Optimisation of supportive care is paramount to allow safe delivery with the least possible impact on quality of life of these new treatments, many of which have resulted dramatically improved outcomes across multiple cancer types. This state of the art update summarises advances in supportive care therapies relating to improving the patient experience during and after anti‐cancer treatment, including new anti‐emetics, hair preservation techniques, bone marrow support and improved venous access devices; the ongoing challenge of neurotoxicity; and the advent of multidisciplinary sub‐specialised fields such as cardio‐oncology and oncofertility. Supportive care medications for immuno‐oncology therapies is a new section; these highly effective (although not universally so) agents were a mere illusion in 1993.

Pre-treatment assessment for patients with breast cancer undergoing chemotherapy: a best practice implementation project

OBJECTIVES

This project aimed to conduct an audit of pre-treatment assessment for patients with breast cancer undergoing chemotherapy and to assess the impact of these changes in improving the compliance with evidence-based best practice criteria in a large tertiary hospital.

INTRODUCTION

Pre-treatment assessment before cancer chemotherapy is paramount in order for patients to receive effective and safe treatment. Numerous guidelines and consensus-based standards for safe chemotherapy administration have been developed, which state that nurses should conduct and document comprehensive health assessments for patients prior to administration of chemotherapy.

METHODS

The project was conducted in the Breast Surgery Department of a nearly 3000-bed tertiary hospital in China. Evidence-based audit criteria were developed based on a JBI evidence summary. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit tool were used to promote changes in practice. Sample sizes of 13 clinical nurses and 30 breast cancer patients undergoing chemotherapy were included in baseline and follow-up audits.

RESULTS

The baseline audit indicated significant deficits in pre-treatment assessment nursing practice in the unit, with eight of the 12 criteria recording 0% compliance and one criterion recording only 3% compliance. Barriers to compliance were identified by the project team, and a series of strategies were adopted to address the barriers. There was improvement in compliance with all the best practice criteria in the follow-up audit compared with the baseline audit, with each one achieving a minimum of 90% compliance.

CONCLUSIONS

The project showed that regular and focused education and ongoing audits on pre-treatment assessment can help to optimize safe and effective chemotherapy treatment. Further strategies are planned to sustain the implementation of evidence.

The scalp cooling therapy for hair loss in breast cancer patients undergoing chemotherapy: a systematic review and meta-analysis

PURPOSE

To systematically assess the efficacy and side effects of scalp cooling in patients with breast cancer.

METHODS

A systematic literature search was conducted in October 2020 across Cochrane Library, PubMed, Embase, CINAHL, Web of Science, Scopus, and four Chinese databases (CNKI, Wanfang, SinoMed, and VIP database). Our review included all randomized controlled trials, cohort studies, and cross-sectional studies. Two authors independently searched databases, screened studies, extracted data, and evaluated each included study's methodological quality and risk bias. Meta-analysis was performed using Stata 15.1 software package and Revman 5.3 software, with estimates of scalp cooling effect and its side effects from pooled using a random-effects model. This study has been registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42020216224).

RESULTS

In total, 755 articles were screened and data from 27 studies involving 2202 participants were used in the meta-analysis. Studies meeting inclusion and exclusion criteria were three randomized clinical trials, 12 cohort studies, and 12 cross-sectional studies. The effectiveness rate of using a scalp cooling device to protect hair was 61% (95% CI: 55 to 67%, I² = 88%, P = 0.000). However, scalp cooling therapy's side effects are not be ignored, such as headache, dizziness, scalp pain, neck pain, feeling cold, heaviness of the head, skin rash, nausea, and overtightened strap.

CONCLUSIONS

This review shows that scalp cooling devices can significantly improve the patients with breast cancer chemotherapy-induced alopecia, but the implications of its side effects provide guide for the implementation of this technology.

Prospective study of hair recovery after (neo)adjuvant chemotherapy with scalp cooling in Japanese breast cancer patients

PURPOSE

Scalp cooling during chemotherapy infusion to mitigate alopecia for breast cancer patients is becoming widespread; however, studies regarding hair recovery after chemotherapy with scalp cooling are limited. We conducted a prospective study of hair recovery after chemotherapy with scalp cooling.

PATIENTS AND METHODS

One hundred and seventeen Japanese female breast cancer patients who completed planned (neo)adjuvant chemotherapy using the Paxman Scalp Cooling System for alopecia prevention were evaluated for alopecia prevention in our prospective study. We evaluated their hair recovery 1, 4, 7, 10, and 13 months after chemotherapy. Primary outcomes were grades of alopecia judged by two investigators (objective grades) and patients' answers to the questionnaire regarding the use of a wig or hat (subjective grades).

RESULTS

Of 117 patients, 75 completed scalp cooling during the planned chemotherapy cycles (Group A), but 42 discontinued it mostly after the first cycle (Group B). Objective and subjective grades were significantly better in Group A than in Group B throughout 1 year, and at 4 and 7 months after chemotherapy. When we restricted patients to those with objective Grade 3 (hair loss of > 50%) at 1 month, Group A exhibited slightly faster hair recovery based on the objective grades than Group B. There was less persistent alopecia in Group A than in Group B.

CONCLUSIONS

Scalp cooling during chemotherapy infusion for Japanese breast cancer patients increased the rate of hair recovery and had preventive effects against persistent alopecia.

Preventive effect of edaravone ointment on cyclophosphamide-chemotherapy induced alopecia

PURPOSE

We evaluated the preventive effect of the antioxidant edaravone (EDR) on chemotherapy-induced alopecia (CIA) to improve quality of life in cancer patients.

METHODS

Hair loss was induced by intraperitoneally administering cyclophosphamide (CPA, 75 mg/kg) to rats, and topically applying EDR ointment (100 mg/day) once daily for 16 days (when hair loss starts) or 21 days (just before hair growth). The rats were divided into four groups: control group (without CPA or EDR), EDR 0% group (CPA + EDR 0%), EDR 3% group (CPA + EDR 3%), and EDR 30% group (CPA + EDR 30%). The prevention of CIA was evaluated by the hair coverage score (five levels from 0 to 4). Furthermore, we measured the size of the hair follicle area and the expression levels of insulin-like growth factor (IGF)-1 mRNA in dermal papilla cells.

RESULTS

The EDR 3% and EDR 30% groups exhibited higher hair coverage scores than the EDR 0% group on day 16 and day 21. On day 16, the hair follicle area in the EDR 3% and EDR 30% groups was significantly larger than that in the EDR 0% group. Furthermore, IGF-1 expression levels in the EDR 3% group were significantly higher than those in the EDR 0% group. On day 21, no significant difference was observed in hair follicle area or IGF-1 mRNA levels among the groups.

CONCLUSION

Our results show that EDR administration lessened hair loss due to CPA in a dose-independent manner above doses of 3%, suggesting potential applications beside chemotherapy.

Association Between ABCB1 Genetic Variants and Persistent Chemotherapy-Induced Alopecia in Women With Breast Cancer

Importance

Persistent chemotherapy-induced alopecia (pCIA) has been recently described in patients with breast cancer and in its most severe form occurs in up to 10% of these patients. Genetic risk factors associated with pCIA have not been adequately explored.

Objective

To identify genetic variants associated with pCIA.

Design, Setting, and Participants

In this genetic association study, 215 women with breast cancer treated with docetaxel-based chemotherapy with a follow-up of 1.5 to 10 years after the end of the treatment were recruited retrospectively through 3 hospital oncology units across Spain between 2005 and 2018. Severe pCIA was defined as lack of scalp hair recovery (Common Terminology Criteria for Adverse Events, version 3.0, grade 2) 18 months or more after the end of treatment. Patients with grade 2 pCIA were selected as cases, and those with no sign of residual alopecia 12 months after the end of docetaxel treatment were selected as controls. A genome-wide association study in a discovery phase was conducted, and logistic regression was used to identify variants associated with the risk to develop this adverse effect. The validity of the association was addressed through a replication phase.

Exposures

Docetaxel-based chemotherapy.

Main Outcomes and Measures

Genotypes of single-nucleotide variants associated with pCIA.

Results

In total, 215 women with breast cancer (median age, 51.6 years; interquartile range, 44-60 years) were recruited (173 patients for the discovery phase and 42 patients for the replication phase). In the discovery phase, ABCB1 genetic variants were associated with risk to develop pCIA. In particular, single-nucleotide variation rs1202179, a regulatory variant located in an enhancer element that interacts with the ABCB1 promoter, was associated with the occurrence of pCIA. This finding was validated in the replication cohort (combined odds ratio, 4.05; 95% CI, 2.46-6.67; P = 3.946 × 10-8). This variant is associated with ABCB1 mRNA expression, and the risk allele was associated with decreased ABCB1 expression levels (P = 1.64 × 10-20).

Conclusions and Relevance

This is the first study, to our knowledge, that identifies an association between a regulatory variant in the ABCB1 gene and the occurrence of pCIA in patients with breast cancer who were treated with docetaxel-based therapies. This finding suggests an important insight into the biological mechanisms underlying pCIA and opens the opportunity to explore personalized treatment of these patients.

Does Scalp Cooling Have the Same Efficacy in Black Patients Receiving Chemotherapy for Breast Cancer?

LESSONS LEARNED

Despite U.S. Food and Drug Administration approval to reduce alopecia, data on efficacy of scalp cooling in Black patients with cancer are limited by lack of minority representation in prior clinical trials. Scalp cooling devices may have less efficacy in Black patients; additional studies are required to explore the possible causes for this, including hair texture and cap design.

BACKGROUND

The Paxman scalp cooling (SC) device is U.S. Food and Drug Administration (FDA)-approved for prevention of chemotherapy-induced alopecia. Studies report 50%-80% success rates and high patient satisfaction, yet there have been no studies of SC in Black patients. We conducted a phase II feasibility study of Paxman SC with a planned enrollment of 30 Black patients receiving chemotherapy for stage I-III breast cancer.

METHODS

Black patients who planned to receive at least four cycles of chemotherapy with non-anthracycline (NAC) or anthracycline (AC) regimens were eligible. Alopecia was assessed by trained oncology providers using the modified Dean scale (MDS) prior to each chemotherapy session. Distress related to alopecia was measured by the Chemotherapy Alopecia Distress Scale (CADS).

RESULTS

Fifteen patients enrolled in the intervention before the study was closed early because of lack of efficacy. Median MDS and CADS increased after SC, suggesting increased hair loss (p < .001) and alopecia distress (p = .04). Only one participant was successful in preventing significant hair loss; the majority stopped SC before chemotherapy completion because of grade 3 alopecia (>50% hair loss).

CONCLUSION

SC may not be efficacious in preventing alopecia in Black women. Differences in hair thickness, hair volume, and limitations of cooling cap design are possible contributing factors.

Scalp cooling in breast cancer patients treated with docetaxel-cyclophosphamide: patient- and nurse-reported results

PURPOSE

Recent evidence supports the efficacy of scalp cooling in preventing chemotherapy-induced alopecia in breast cancer treatments. However, efficacy largely varies between treatment regimens. The aim of this study was to explore the patient- and nurse-reported results of scalp cooling in terms of hair loss and need for a wig/head cover in patients with breast cancer treated with 3-weekly docetaxel 75 mg/m²- cyclophosphamide 600 mg/m².

METHODS

We studied nurse-reported efficacy as noted in the electronic patient files of 85 patients treated with docetaxel 75 mg/m²- cyclophosphamide 600 mg/m² between 1/1/2017 and 1/1/2020. Sixty-nine of them also self-reported on their scalp cooling results up to one year after adjuvant chemotherapy in a retrospective way.

RESULTS

Nurse- and patient-reported data showed that scalp cooling was successful (i.e., hair loss < 50%) in 47.1 and 44.9% of patients, respectively, and 55% of patients were (very) satisfied with the result of scalp cooling. Scalp cooling was perceived as (very) uncomfortable in 36.2% of patients. Regarding hair status one year after treatment, 47 patients (55.3%) reported no changes compared to their hair status before treatment.

CONCLUSIONS

Scalp cooling is successful in preventing severe chemotherapy-induced alopecia in almost half of the patients with breast cancer treated with docetaxel 75 mg/m²- cyclophosphamide 600 mg/m². Better understanding of the success rate of scalp cooling enables correct patient information and decision-making support.

Multicenter randomized controlled trial to evaluate the efficacy and tolerability of frozen gloves for the prevention of chemotherapy-induced peripheral neuropathy

BACKGROUND

This study investigated the efficacy and tolerability of wearing frozen gloves (FGs) during chemotherapy to prevent chemotherapy-induced peripheral neuropathy (CIPN) as reported by patients and influence on quality of life (QoL).

PATIENTS AND METHODS

Cancer patients starting treatment with oxaliplatin, docetaxel or paclitaxel between February 2013 and May 2016 at the medical oncology department were eligible. Patients were randomized into groups wearing FGs on both hands during treatment and those not wearing FGs during treatment. Self-reported CIPN and QoL were measured with the European Organisation for the Research and Treatment of Cancer Quality of Life (EORTC QLQ) CIPN20 and QLQ-C30 at four time points: baseline (t₀), after three cycles (t₁), end of chemotherapy (t₂) and after 6 months (t₃).

RESULTS

The study included 180 patients with 90 patients in both arms. They mostly underwent treatment of colorectal or breast cancer. Thirty-one patients (34%) discontinued FGs, mainly due to discomfort. Intention-to-treat analyses showed no important differences in reported EORTC QLQ CIPN20 subscales between the FG group and control group; however, the analyses showed the patients experienced reduced tingling in fingers/hands [β = -10.20, 95% confidence interval (CI) = -3.94 to -3.14, P = 0.005] and less trouble opening a jar or bottle due to loss of strength in hands (β = -6.97, 95% CI = -13.53 to -0.40, P = 0.04) in the FG group compared with the control group. Per-protocol analyses showed similar results: reduced aching or burning pain in fingers/hands (β = -4.37, 95% CI = -7.90 to -0.83, P = 0.02) and cramps in hands (β = -3.76, 95% CI = -7.38 to -0.14, P = 0.04). Differences in tingling in fingers/hands at t₁ were clinically relevant. In addition, those treated with FGs reported overall better QoL (β = 4.79, 95% CI = 0.37 to 9.22, P = 0.03) and physical functioning (β = 5.66, 95% CI = 1.59 to 9.73, P = 0.007) than the control. No difference in dose reductions was observed.

CONCLUSIONS

No difference in CIPN subscales was reported between intervention arms. Wearing FGs might reduce some neuropathy symptoms in the hands, potentially resulting in a better QoL; however, one-third of the FG group discontinued the study before the end of treatment. Future studies should focus on the method of limb hypothermia to prevent CIPN.

TRIAL REGISTRATION NUMBER

NL39650.015.12.

Safety and efficacy of scalp cooling system in preventing chemotherapy induced alopecia - A single center prospective study

BACKGROUND

Alopecia is one of the most common and afflicting side effects associated with chemotherapy treatments. Scalp-cooling devices were introduced to reduce hair loss and improve the hair volume recovery in patients undergoing chemotherapy.

METHODS

This is a single center, prospective observational study conducted from 01 February 2019 to 31 January 2020, in patients undergoing chemotherapy for various cancers. The extent of alopecia was assessed by two independent clinicians by reviewing the photographs taken at baseline, during each session, and 4 weeks from the last scalp cooling session.

RESULTS

A total of 100 patients (female: 94 and male: 6) were enrolled in the study, with a mean age of 53.5 years. Of 100 patients, 40 received anthracycline based chemotherapy, 45 received taxane based chemotherapy, 9 received both, and 6 received other chemotherapeutic agents. By the end of the study, 31 patients experienced grade 0-1 alopecia and 69 patients had grade 2 alopecia. On multivariate analysis, chemotherapeutic agent was found to be an independent factor for delaying the onset of Grade 2 alopecia (anthracycline vs taxanes (OR: 0.71; 95% CI (0.51-0.92); P ≤ 0.04)The most common adverse events reported during the scalp cooling sessions were chills (7%), and chills with headaches (6%). Scalp metastasis and scalp cooling discontinuation rates were observed to be very rare. No serious adverse events related to device were observed.

CONCLUSION

Scalp cooling was observed to be more effective in reducing chemotherapy-induced alopecia in patients treated with taxane-based chemotherapy over anthracyclines. Scalp cooling sessions were well tolerated. Scalp metastasis and scalp cooling discontinuation was observed to be very rare.

The Experiences and Support Needs of Women With Gestational Breast Cancer in Singapore: A Descriptive Qualitative Study

BACKGROUND

Gestational breast cancer is diagnosed during pregnancy or within the first postpartum year. There is a lack of studies on the experiences of ethnically diverse Asian women with gestational breast cancer.

OBJECTIVE

The aim of this study was to explore the experiences of Asian women with gestational breast cancer so necessary support can be rendered.

METHODS

This qualitative descriptive study used purposive sampling to recruit 7 women with gestational breast cancer who were following up at the breast center of a tertiary women's hospital in Singapore. Semistructured, individual, face-to-face, audio-recorded interviews were used to explore the in-depth experiences of these women. Data were transcribed verbatim and analyzed using thematic analysis.

RESULTS

Three main themes emerged from the thematic analysis: (1) being a sick woman, (2) juggling between being a mother and a patient, and (3) seeking normalcy. Women had to contend with disruptive changes from gestational breast cancer, both emotionally and physically. They were constantly distressed by their altered body images, and family support was vital to help these women cope with their treatments. Alternative support sources included healthcare professionals and the Internet.

CONCLUSION

Gestational breast cancer experiences varied based on the women's encounter perceptions and existing support. Their experiences may be improved through further support to mediate their coping efforts. Future quantitative and qualitative research should explore and evaluate the various aspects of the long-term disease and psychosocial effects of gestational breast cancer.

IMPLICATIONS FOR PRACTICE

Hospitals should include support strategies in antenatal classes and postnatal workshops to lessen disruptions of the motherhood experiences.

A phase I safety study of topical calcitriol (BPM31543) for the prevention of chemotherapy-induced alopecia

PURPOSE

Chemotherapy-induced alopecia (CIA) negatively affects psychosocial health and quality of life (QoL). Currently, there are no approved pharmacologic agents to prevent CIA. Here, we evaluated the safety, tolerability, and potential signal of efficacy of topical calcitriol (BPM31543) on CIA prevention.

MATERIALS AND METHODS

This Phase 1 trial included 23 female patients with breast cancer, gynecologic cancer, or sarcomas receiving a taxane-based chemotherapy. Patients received a 3 + 3 dose-escalation regimen at 5, 10, 20, 40, 60, and 80 μg/mL, with 3-6 patients per group. Patients applied topical BPM31543 to the scalp twice a day for 2 weeks prior to chemotherapy and continued until chemotherapy treatment was completed. The maximum tolerated dose (MTD) during first 28 day application was determined. Adverse event (AE) monitoring, pharmacokinetics, blinded photographic assessments, and patient self-assessment were evaluated.

RESULTS

Out of 23 patients treated with BPM31543, 8 patients experienced at least 1 treatment-related adverse event (AE). The majority of AEs were mild to moderate in severity. Only 1 patient experienced SAEs (vomiting, nausea, fever, and flank pain) considered treatment related. Alopecia < 50% from baseline was observed in 8 patients at Week 7, and, of which 2 patients had < 50% alopecia maintained at Week 15. There were no detectable effects of topical BPM31543 on serum levels of calcitriol.

CONCLUSIONS

BPM31543 applied topically twice daily to the scalp is safe and well tolerated in patients receiving taxane-based chemotherapy. No DLT was observed at up to 80 µg/mL, and MTD was not reached. Based on the data from this trial, BPM31543 represents a promising therapy and warrants further investigation in Phase 2/3 trials.

Impact of chemotherapy regimen and sequence on the effectiveness of scalp cooling for alopecia prevention

PURPOSE

Scalp cooling (SC) is the most reliable method for the prevention of chemotherapy-induced alopecia. However, it remains unclear if its effectiveness is related to the chemotherapy regimen, sequence, and frequency. This study aims to evaluate SC performance among breast cancer patients who received different chemotherapy regimens.

METHODS

The medical records of all consecutive patients undergoing curative-intent chemotherapy and receiving at least one SC session using the DigniCap® System from 2016-2020 in a private Mexican hospital were retrospectively reviewed. SC effectiveness according to chemotherapy regimen was analyzed using descriptive statistics. Successful alopecia prevention was defined as grade 0-1 alopecia (< 50% hair loss not requiring the use of a wig or headpiece) according to the Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

SC adequately prevented alopecia in 56/76 (74%) patients. All 12/12 (100%) and 15/17 (88%) patients receiving paclitaxel-only and docetaxel-based chemotherapy, respectively, had effective hair preservation. SC was successful in 7/16 (44%) patients when sequential chemotherapy started with anthracyclines and 22/30 (73%) when paclitaxel was administered upfront. Considering dose-dense regimens, 9/15 (60%) had satisfactory hair retention, and chemotherapy sequence was not clearly related to SC success.

CONCLUSION

SC was highly effective in preventing alopecia, particularly with taxane-based regimens. Notably, better outcomes were observed when sequential chemotherapy started with taxanes followed by anthracyclines than when the inverse order was administered, suggesting that the chemotherapy sequence, rather than chemotherapeutic agents per se, might have a more significant impact on the effectiveness of SC for the prevention of alopecia.

Cooling-mediated protection from chemotherapy drug-induced cytotoxicity in human keratinocytes by inhibition of cellular drug uptake

Chemotherapy-induced alopecia (CIA) represents the most distressing side-effect for cancer patients. Scalp cooling is currently the only treatment to combat CIA, yet little is known about its cytoprotective effects in human hair follicles (HF). We have previously established in vitro human keratinocyte models to study the effects of taxanes and anthracyclines routinely-used clinically and reported that cooling markedly-reduced or even completely-prevented cytotoxicity in a temperature dependent manner. Using these models (including HF-derived primary keratinocytes), we now demonstrate that cooling markedly attenuates cellular uptake of the anthracyclines doxorubicin and epirubicin to reduce or prevent drug-mediated human keratinocyte cytotoxicity. We show marked reduction in drug uptake and nuclear localization qualitatively by fluorescence microscopy. We have also devised a flow cytometry-based methodology that permitted semi-quantitative analysis of differences in drug uptake, which demonstrated that cooling can reduce drug uptake by up to ~8-fold in comparison to normal/physiological temperature, an effect that was temperature-dependent. Our results provide evidence that attenuation of cellular drug uptake represents at least one of the mechanisms underpinning the ability of cooling to rescue human keratinocytes from chemotherapy drug-cytotoxicity, thus supporting the clinical efficacy of scalp cooling.

Efficacy of the DigniCap System in preventing chemotherapy-induced alopecia in breast cancer patients is not related to patient characteristics or side effects of the device

BACKGROUND

The DigniCap System is an effective scalp cooling device for the prevention of chemotherapy-induced alopecia in early breast cancer patients.

AIM

This prospective study was designed to confirm the efficacy and tolerability of the device, to explore potential factors associated with its efficacy and to collect data on patient perceptions and satisfaction.

METHODS

Between January 2016 and June 2018, 163 early breast cancer patients eligible for adjuvant chemotherapy were enrolled. Hair loss was assessed using the Dean scale, where a score of 0-2 (hair loss ≤50%) was defined as successful.

RESULTS

Hair preservation was successful in 57% of patients in the overall series. The proportion was even higher (81%) in the patient subgroup treated with a paclitaxel and trastuzumab regimen. Side effects (feeling cold, headache, head heaviness, scalp and cervical pain) were mild to moderate and did not correlate with the rate of hair loss. Lifestyle, anthropometric factors and hair characteristics failed to be associated with device efficacy.

CONCLUSIONS

The DigniCap System was well tolerated and found to be effective in preventing alopecia in early breast cancer patients. Our study failed to identify factors other than type of chemotherapy regimen associated with hair preservation.

Management of chemotherapy-induced alopecia (CIA): A comprehensive review and future directions

OBJECTIVES

To review and summarize the available literature on the management of chemotherapy-induced alopecia (CIA) including complementary and alternative medicine (CAM), and to present CIA's effect on quality of life (QoL).

METHODS

Nine databases were searched for CIA-related keywords, including the effect on QoL, and management options. Among 1019 articles found, 54 articles focusing on treatment/prevention or QoL were retrieved. References of selected articles were also checked manually.

RESULTS

CIA was found to negatively affect QoL and body image, regardless of head covering status (i.e., for cultural or religious reasons). Most studies related to treatment/prevention of CIA reported on the use of scalp-cooling. The efficacy of CAM treatments was found to be questionable.

CONCLUSION

A high incidence rate of CIA exists with certain chemotherapies, and it significantly impairs QoL. Preventive and treatment strategies are incompletely effective. Additional literature is needed to explore potential preventive or therapeutic options for CIA.

Prospective observational study of chemotherapy-induced alopecia after sequential FEC + taxane and the effects of age in breast cancer patients

BACKGROUND

Chemotherapy-induced alopecia (CIA) is a common and quite distressing adverse effects of chemotherapy. There are few detailed observational studies of CIA or of the impact of age on CIA. We performed a prospective observational study to investigate the prevalence and degree of CIA, including CIA of eyebrows, eyelashes, and body, and we examined patient's recovery from CIA, focusing on age-depending effects.

METHODS

We analyzed 68 female Japanese patients with breast cancer (median age 53 years, range 29-76 years) who received perioperative adjuvant chemotherapy with fluorouracil/epirubicin/cyclophosphamide (FEC) and taxane. A questionnaire was administered at the point of chemotherapy completion and 6 and 12 months after chemotherapy completion.

RESULTS

CIA occurred in all patients, with severe hair loss irrespective of age. CIA occurred mainly in the scalp but also in the eyebrows, eyelashes, and body for most of the patients. There were significant associations between the patient's age and the onset of hair regrowth in the eyebrows, eyelashes, and body. The onset of eyebrows, eyelash, and body hair growth were significantly shorter in the premenopausal patients. Any hair changes (e.g., thinned diameter, softer texture, curlier structure) were reported by 85.3% of the patients.

CONCLUSIONS

Severe CIA occurred in all 68 patients who received FEC and taxane chemotherapy. The present findings provide the first data demonstrating that age was not associated with the degree or incidence of hair loss, but age affected the recovery from CIA. These results contribute more accurate information provision and insights regarding the proper treatment of CIA.

Targeted Therapy- and Chemotherapy-Associated Skin Toxicities: Systematic Review and Meta-Analysis

PROBLEM IDENTIFICATION

Preventing and managing skin toxicities can minimize treatment disruptions and improve well-being. This systematic review aimed to evaluate the effectiveness of interventions for the prevention and management of cancer treatment-related skin toxicities.

LITERATURE SEARCH

The authors systematically searched for comparative studies published before April 1, 2019. Study selection and appraisal were conducted by pairs of independent reviewers.

DATA EVALUATION

The random-effects model was used to conduct meta-analysis when appropriate.

SYNTHESIS

39 studies (6,006 patients) were included; 16 of those provided data for meta-analysis. Prophylactic minocycline reduced the development of all-grade and grade 1 acneform rash in patients who received erlotinib. Prophylaxis with pyridoxine 400 mg in capecitabine-treated patients lowered the risk of grade 2 or 3 hand-foot syndrome. Several treatments for hand-foot skin reaction suggested benefit in heterogeneous studies. Scalp cooling significantly reduced the risk for severe hair loss or total alopecia associated with chemotherapy.

IMPLICATIONS FOR RESEARCH

Certainty in the available evidence was limited for several interventions, suggesting the need for future research.

SUPPLEMENTAL MATERIAL CAN BE FOUND AT&NBSP;HTTPS

//onf.ons.org/supplementary-material-targeted-therapy-and-chemotherapy-associated-skin-toxicity-systematic-review.

A Chinese version of the chemotherapy-induced alopecia distress scale based on reliability and validity assessment in breast cancer patients

PURPOSE

Chemotherapy-induced alopecia is a common and emotionally traumatic side effect on breast cancer patients. In order to make up for the deficiency of measuring tools in China, our study aims at translating the chemotherapy-induced alopecia distress scale (CADS) into Chinese and evaluating the psychometric properties of the Chinese version of CADS (CADS-C) in breast cancer patients.

METHODS

The validity and reliability of CADS-C were measured by a questionnaire survey among 301 breast cancer patients from Chinese mainland. Construct validity was assessed through factor analysis and contrasted group comparisons. The validity of the content was examined by an experts group. The internal consistency and test-retest reliability were evaluated by calculating Cronbach's alpha and the intraclass correlation coefficient.

RESULTS

The content validity index was 0.94; a structure with three factors was revealed by exploratory factor analysis which explained 65.40% of the variance and proved by confirmatory factor analysis. The contrasted group comparisons showed significant differences among different degrees of alopecia. The average variance extracted and composite reliability and correlations between CADS and body image, quality of life and self-esteem proved the convergent validity. The Cronbach's alpha and the intraclass correlation coefficient of the total scale were 0.90 and 0.89 respectively, indicating satisfactory internal consistency and time stability.

CONCLUSION

The scale appears to be a reliable and valid tool to measure chemotherapy-induced alopecia distress among breast cancer patients in China.

ONS Guidelines™ for Cancer Treatment-Related Skin Toxicity

BACKGROUND

Management of cancer treatment-related skin toxicities can minimize treatment disruptions and improve patient well-being.

OBJECTIVES

This guideline aims to support patients and clinicians in decisions regarding management of cancer treatment-related skin toxicities.

METHODS

A panel developed a guideline for management of cancer treatment-related skin toxicities using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) for certainty of evidence and the National Academies of Sciences, Engineering, and Medicine criteria for trustworthy guidelines. The Cochrane risk-of-bias tool assessed risk of bias. A quantitative or narrative synthesis of the evidence was completed.

RESULTS

The panel issued seven conditional recommendations for epidermal growth factor receptor inhibitor rash, hand-foot skin reaction, hand-foot syndrome, and chemotherapy-induced alopecia. The panel suggested strategies for prevention and treatment for all toxicities except hand-foot syndrome, which only has a prevention recommendation.

IMPLICATIONS FOR NURSING

Cancer treatment-related skin toxicities can significantly affect quality of life. Incorporation of these interventions into clinical care can improve patient outcomes.

SUPPLEMENTARY MATERIAL CAN BE FOUND AT&NBSP;HTTPS

//onf.ons.org/supplementary-material-ons-guidelines-cancer-treatment-related-skin-toxicity.

Efficacy of Oral Cryotherapy During Oxaliplatin Infusion in Preventing Oral Thermal Hyperalgesia: A Randomized Trial

BACKGROUND

Chemotherapy-induced oral thermal hyperalgesia (OTH) is a common and debilitating side effect of platinum-based anticancer agents. This study evaluated the efficacy of oral cryotherapy in preventing OTH during oxaliplatin chemotherapy infusion.

METHODS

Patients with gastrointestinal cancer treated with biweekly oxaliplatin (85 mg/m2 over 120 minutes) at Abramson Cancer Center at the University of Pennsylvania were randomized to receive oral cryotherapy (ice chips) during oxaliplatin infusion or standard-of-care treatment. All patients completed baseline questionnaires regarding oral and peripheral symptoms and on-treatment questionnaires on day 1 of each subsequent chemotherapy cycle. Those in the treatment arm were asked to document how long they kept the ice chips in their mouths (0, <30, 30, 60, 90, or 120 minutes) and to report their discomfort associated with oral cryotherapy. Evaluable patients were those who had completed at least 2 cycles of oxaliplatin therapy.

RESULTS

Of 62 randomized patients with a variety of gastrointestinal malignancies, 50 (25 per treatment arm) were evaluable for efficacy. The rate of patients with oral symptoms after the first treatment cycle was significantly lower in the intervention arm (n=8; 32%) than in the control arm (n=18; 72%), meeting the primary study objective (P=.01). The magnitude of difference in symptom scores before versus after the first treatment cycle was significantly less in the intervention versus control arm (P=.001). No difference in oral symptoms over time was seen between the intervention and control groups (P=.20), although a high attrition rate was noted. Duration of ice chip exposure was associated with improved oral symptoms over time (P=.02).

CONCLUSIONS

Oral cryotherapy is a tolerable and cost-effective method of diminishing OTH in patients receiving oxaliplatin chemotherapy, and seems to be most effective in the early stages of treatment.

Geographic disparities in access to scalp cooling for the prevention of chemotherapy-induced alopecia in the United States

BACKGROUND

Chemotherapy-induced alopecia is psychologically challenging for patients undergoing cancer treatment, and scalp cooling has been shown to prevent or decrease the hair loss.

OBJECTIVE

To evaluate whether access to scalp cooling varies by geographic area in the United States.

METHODS

Cancer treatment centers offering scalp cooling were identified using data from the Rapunzel Project. Medicare claims data were queried to evaluate the number of chemotherapy infusions occurring in each zip code in the United States. Geographic distribution of chemotherapy infusions and scalp cooling centers was determined using ArcGIS software. The average distance from the geographic center of all 5-digit zip codes in which chemotherapy infusions occur to the nearest scalp cooling center was calculated in miles.

RESULTS

There are 366 chemotherapy infusion centers in the United States that offer scalp cooling. Overall, 43.9% of Medicare-billed chemotherapy infusions in the United States occur in zip codes less than 12.5 miles from a scalp cooling center, 24.8% occur between 12.5 and 49.9 miles away, and 31.3% occur more than 50 miles away.

LIMITATIONS

Our results are only generalizable to patients seen at Medicare-accepting institutions in the United States.

CONCLUSIONS

Geographic disparities affect which patients can access scalp cooling therapy, and implementation in suburban and rural areas would increase access for patients who wish to preserve their hair while undergoing chemotherapy.

Integration of Physician and Nursing Professional Efforts to Deliver Supportive Scalp Cooling Care to Oncology Patients at Risk for Alopecia

Scalp cooling (SC) is an effective and generally well-tolerated method for prevention of chemotherapy-induced alopecia (CIA). Initially studied in early-stage breast cancer, these devices have expanded US Food and Drug Administration (FDA) clearance in a broad range of solid tumors including ovarian, colorectal, and prostate. Introducing SC to eligible patients, including those distraught by concerns of CIA, requires an integrated effort on the part of the physician, nursing, and care manager medical team. This article presents a pragmatic workflow for collaborative efforts from physicians and allied health professionals in the USA to deliver supportive SC to reduce CIA in patients undergoing treatment regimens known to impact hair follicles. It further highlights the efforts required to identify appropriate patients, educate, and set expectations of patients. The supervisory role of the physician during the procedure, the nursing role in monitoring and documentation, and the post-procedure decision-making by the physician are also addressed. Lastly, it suggests that integrated physician and nursing efforts necessary for scalp cooling are similar to other care used in oncology.

Scalp cooling to prevent chemotherapy-induced alopecia

Chemotherapy-induced alopecia causes an important impact on cancer patients and its risk of persistence is currently a considerable issue in cancer survivors. Of the various interventions proposed for the prevention of chemotherapy-induced alopecia, scalp cooling has emerged as an effective and safe strategy. This paper aims to provide an overview on scalp cooling and chemotherapy-induced alopecia prevention.

Scalp cooling for hair loss prevention in female Japanese breast cancer patients receiving (neo)adjuvant chemotherapy

PURPOSE

Scalp cooling during chemotherapy infusion has been recently reported to have moderate efficacy in the mitigation of chemotherapy-induced alopecia; however, there are few reports on Asian patients. We aimed to clarify the effects of scalp cooling in Japanese women.

PATIENTS AND METHODS

Female Japanese breast cancer patients who planned to receive (neo)adjuvant chemotherapy participated in this prospective study on the efficacy of scalp cooling using the Paxman Scalp Cooling System for alopecia prevention. The primary outcomes were the rates of patients with Grade 3 alopecia (defined as hair loss of > 50%) and the rates of patients who used a wig or hat to conceal hair loss 1 month after the last infusion of chemotherapy. The subjects were given a brief questionnaire regarding headaches, bad mood, fatigue, and chills shortly after each cooling.

RESULTS

One hundred and forty-three patients participated in the study and used the cooling cap at least once. The mean and median ages of the subjects were 50.6 and 50, respectively (age range 28-76). One hundred and twenty-nine patients completed the planned chemotherapy of 4 to 8 cycles. Among them (7 patients were not evaluable), 74 patients (60.7%) had Grade 3 alopecia 1 month after chemotherapy. Of 80 patients who used the scalp cooling system throughout the planned chemotherapy (1 patient was not evaluable), 36 patients (45.6%) experienced Grade 3 alopecia.

CONCLUSION

The efficacy of scalp cooling during chemotherapy infusion for hair loss mitigation in Asian women is similar to that in Caucasian women.

Role of increased vascular permeability in chemotherapy-induced alopecia: In vivo imaging of the hair follicular microenvironment in mice

Chemotherapy-induced alopecia is one of the most difficult adverse events of cancer treatment for patients. However, it is still unknown why anticancer drugs cause hair loss. We aimed to clarify the mechanism of chemotherapy-induced alopecia in mice using an in vivo imaging technique with a two-photon microscope, which enables observation of the deep reaction in the living body in real time. In this study, ICR mice were injected intraperitoneally with cyclophosphamide (120 µg/g). Changes in the hair bulb morphology, subcutaneous vessel permeability, and vessel density were evaluated by two-photon microscopy and conventional methods. In order to determine whether there is a causal relationship between vascular permeability and hair loss, we combined cyclophosphamide (50 µg/g) with subcutaneous histamine. Using two‐photon microscopy and conventional examination, we confirmed that the hair bulbs became smaller, blood vessels around the hair follicle decreased, and vascular permeability increased at 24 hours after cyclophosphamide injection [corrected]. Apoptosis occurred in vascular endothelial cells around the hair follicle. Additionally, hair loss was exacerbated by temporarily enhancing vascular permeability with histamine. In conclusion, cyclophosphamide caused a decrease in vascular density and an increase in vascular permeability, therefore increased vascular permeability might be one of the causes of chemotherapy-induced alopecia.

Breast Cancer, Version 3.2020, NCCN Clinical Practice Guidelines in Oncology

Several new systemic therapy options have become available for patients with metastatic breast cancer, which have led to improvements in survival. In addition to patient and clinical factors, the treatment selection primarily depends on the tumor biology (hormone-receptor status and HER2-status). The NCCN Guidelines specific to the workup and treatment of patients with recurrent/stage IV breast cancer are discussed in this article.

Berberine Reverses Doxorubicin Resistance by Inhibiting Autophagy Through the PTEN/Akt/mTOR Signaling Pathway in Breast Cancer

PURPOSE

Berberine (BBR), a traditional Chinese medicine, has been shown effects on inhibiting cancer development. Autophagy-mediated resistance plays an important role in cancer progression; therefore, regulation of autophagy is a novel therapeutic strategy for cancer treatment. However, effects of BBR on autophagy-mediated resistance have not been reported.

METHODS

MCF-7 breast cancer cells and the doxorubicin (ADR)-resistant MCF-7 cells (MCF-7/ADR) were used for analyses. Western blotting was conducted to evaluate protein expression; MTT, colony formation, and EdU assays were conducted to assess cell proliferation; transmission electron microscopy was used to monitor autophagy levels; and a xenograft tumor model was established to assess the effects of BBR on reversing doxorubicin resistance.

RESULTS

We confirmed that BBR, recently identified as a suppressor of autophagy, inhibits autophagosome formation in MCF-7/ADR cells. Treatment with BBR blocked the accumulation of the autophagy-associated protein LC3II, resulting in cellular accumulation of p62, reduced cell proliferation, and reversal of doxorubicin resistance. Mechanistically, we found that BBR inhibited autophagy by modulating the PTEN/Akt/mTOR signaling pathway. In vivo, our study showed that BBR exerts clear anti-tumor effects.

CONCLUSION

The results of this study suggest that BBR reverses doxorubicin resistance in breast cancer cells by inhibiting autophagy. This finding highlights the potential clinical application of BBR in the treatment of breast cancer.

Management of dermatologic adverse events from cancer therapies: recommendations of an expert panel

With the development of new cancer therapies, systemic toxicity profile and effects on survival achieved an important improvement. However, a constellation of toxicities has emerged, even more remarkably, cutaneous adverse events. This report, developed by a board of Brazilian experts in oncodermatology, aims to establish a guideline for the dermatological care of oncologic patients. When possible, evidence-based recommendations were made, but in many cases, when strong evidence was not available, a consensus was reached, based on some data supporting therapies combined with personal experiences.

Prevention of depression in patients with cancer: A systematic review and meta-analysis of randomized controlled trials

Depression and depressive symptoms are prevalent in patients with cancer. Depression is underdiagnosed and therefore, patients often receive inadequate treatment for depression. We have assessed the evidence of primary prophylactic treatment for depression in patients with cancer. The systematic review was prospectively registered at PROSPERO and was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Five electronic databases were searched on the 31st of May 2018 and two independent reviewers screened the papers. Randomized controlled trials of adult patients with cancer treated prophylactically with an antidepressive intervention of any kind using validated assessment tools to measure depression or depressive symptoms were included. No language or publication year restrictions were applied. Seven out of eighteen studies reported a statistically significant prophylactic effect on depression. The studies were classified into three groups based on the type of intervention. The meta-analyses showed a significant difference in favour of pharmacotherapy (RR 0.34, 95% CI 0.18; 0.63), psychotherapy (SMD -0.23,95% CI -0.46; 0.00), and other interventions (SMD -0.17, 95% CI -0.31; -0.03). Only one study had overall low risk of bias and the rest had high risk of bias predominantly due to blinding, incomplete data, or allocation concealment. Preventive measures have been examined in patients with cancer, but no convincing evidence for any specific intervention is present. Depression in patients with cancer can be prevented and prophylactic treatment should be given during oncological treatment but further high quality studies testing safe interventions are still needed.

Use of scalp cooling device to prevent alopecia for early breast cancer patients receiving chemotherapy: A prospective study

Chemotherapy-induced alopecia (CIA) affects the majority of patients receiving chemotherapy (CT) for early breast cancer. It is a highly distressing side effect of CT, with psychological and social impact. Primary aim of the present analysis was to assess the efficacy of scalp cooling with DigniCap® in preventing CIA. Success rate was defined as patients' self-reported hair loss <50% according to Dean scale. In this analysis, we reported success rate at 3 weeks after the first CT course and at 3 weeks after the last CT course. Secondary endpoints included self-reported tolerability and patients' judgment on scalp cooling performance. Consecutive early breast cancer patients admitted to Istituto Oncologico Veneto who were recommended to receive neoadjuvant or adjuvant CT, were eligible to undergo scalp cooling during the CT administration within this study. 135 patients were included: 74% received adjuvant CT and 26% neoadjuvant CT (P < .001). The type of CT was: docetaxel-cyclophosphamide (26%), paclitaxel (23%), epirubicin-cyclophosphamide followed by paclitaxel (32%), and paclitaxel followed by epirubicincyclophosphamide (19%). The rate of success in preventing alopecia was 77% (104/135) at 3 weeks from the start of CT and 60% (81/135) at 3 weeks from the end of treatment. Higher success rates were reported in non-anthracycline (71%) compared to anthracycline-containing CT regimens (54%; P < 0.001). Premature discontinuation of scalp cooling was reported in 29/135 patients (21.5%), including withdrawal for alopecia (16/29), for low scalp cooling tolerability (8/29) or both (5/29). Scalp cooling was generally well tolerated. These results overall suggest that the use of scalp cooling is effective in preventing alopecia in the majority of early breast cancer patients receiving neoadjuvant or adjuvant CT, especially for patients undergoing a taxane-based non-anthracycline regimen.

"Randomised controlled trial of scalp cooling for the prevention of chemotherapy induced alopecia"

Background

Randomized controlled trials (RCT) of scalp cooling (SC) to prevent chemotherapy induced alopecia (CIA) did not evaluate its effect on hair regrowth (HR) and was conducted in a predominantly taxane (T) treated population. We conducted an RCT of SC in a setting of anthracycline (A) and taxane chemotherapy (CT) and assessed its effect on CIA and HR.

Methods

Non-metastatic breast cancer women undergoing (neo) adjuvant CT were randomized to receive SC using the Paxman scalp cooling system during every cycle of CT, or no SC. The primary end point (PEP) was successful hair preservation (HP) assessed clinically and by review of photographs after CT. HR was assessed at 6 and 12 weeks.

Results

51 patients were randomized to SC (34) or control arm (17) in a 2:1 ratio. Twenty-five (49%) patients received A followed by T and the two arms were balanced with respect to this factor. HP rate was significantly higher in SC arm compared to control arm (56.3% vs 0%, P = 0.000004). HR was higher in SC arm compared to control at 6 weeks (89% vs 12%; P < 0.001) and 12 weeks (100% vs 59%, P = 0.0003). Loss of hair at PEP evaluation, which was a quality of life measure, was significantly lower in SC versus control arm (45% vs 82%, P = 0.016). There were no grade 3–4 cold related adverse effects.

Conclusions

Women with breast cancer receiving A or T chemotherapy receiving SC were significantly more likely to have less than 50% hair loss after CT, superior hair regrowth and improvement in patient reported outcomes, with acceptable tolerance. It merits wider usage.

Dermatologic conditions in women receiving systemic cancer therapy

As advances in cancer therapies have improved cancer-related survival, novel therapeutics have also introduced a variety of dermatologic toxicities, and an increased number of patients are living with these sequalae. Women with cancer in particular experience a spectrum of dermatologic conditions that affect their skin, hair, nail, and mucosal surfaces. Studies have shown that these toxic effects can significantly affect quality of life and alter a woman's self-image, cultural identity, femininity, sexuality, and mental health. In severe instances, dermatologic toxicities may even disrupt cancer therapy and can therefore affect overall survival and treatment response. In this article, we review the dermatologic adverse effects from traditional chemotherapy, targeted therapy, immune checkpoint inhibitors, and endocrine therapy that disproportionately affect women. The timely diagnosis and management of these dermatologic conditions is crucial in the multidisciplinary care of women with cancer.

Final results of a prospective study of scalp cooling in preventing chemotherapy-induced alopecia

Aim: Alopecia is a distressing effect of cancer treatments. Our study examined efficacy and safety of scalp cooling to prevent chemotherapy-induced alopecia. Materials & methods: Early breast cancer patients candidate to anthracycline and/or taxane were eligible. Dean's alopecia scale was used to classify alopecia. Results: From February 2016 to November 2018, 127 women were enrolled; 55 (43.3%) received epirubicin/cyclophosphamide (4 EC 3 weeks) followed by paclitaxel (12 P weeks); 50 (39.4%) received 4 EC 3 weeks; 20 (15.7%) received 12 P weeks/trastuzumab and 2 docetaxel/cyclophosphamide (4 TC 3 weeks). The success rate was 71.7% (G0 21.3%, G1 31.5%, G2 18.9%). Frequent side effects were: coldness, headache, scalp pain and head heaviness. Conclusion: In our study, scalp cooling can prevent alopecia thus supporting the wider use in early breast cancer.