Scalp Cooling: A Literature Review of Efficacy, Safety, and Tolerability for Chemotherapy-Induced Alopecia

Shorter post-infusion cooling times at least as effective as longer cooling times - An observational study of taxane- and anthracycline-based chemotherapies in the Dutch Scalp Cooling Registry

PURPOSE

Chemotherapy-induced alopecia (CIA), a very common and distressing side effect of cancer treatment can be effectively prevented by scalp cooling. The aim of this observational study was to estimate the effect of post-infusion cooling time (PICT) on wearing a head cover for taxane- and anthracycline-based chemotherapies.

METHODS

The Dutch Scalp Cooling Registry (DSCR), which started in January 2006, collected data from 4680 scalp-cooled patients across 68 Dutch hospitals. Questionnaires on patient, chemotherapy and scalp cooling characteristics were completed by patients and nurses. The patient-reported primary outcome included the use of head covering during the final scalp cooling session. Analysis included patients who had received Docetaxel 75 or 100 mg/m2 (D75 or D100), Paclitaxel 70-90 or 160-180 mg/m2 (T70-90 or T160-180), Adriamycin 60 mg/m2 and Cyclophosphamide 600 mg/m2 (AC), or 5-Fluorouracil 500 mg/m2 Epirubicin 90 or 100 mg/m2 and Cyclophosphamide 500 mg/m2 (FE90C or FE100C).

RESULTS

Shorter post-infusion cooling times (< 85 minutes) seem to be sufficient for maintaining scalp cooling effectiveness in the chemotherapy regimens studied, with no added benefit from extending cooling time beyond this threshold.

CONCLUSION

For all anthracycline and taxane-based chemotherapy regimens studied, shorter PICTs delivered comparable results to longer PICTs.

The Efficacy of Paxman Scalp Cooling System in Preventing Hair Loss in Breast Cancer Patients Receiving Chemotherapy in Western India - Multi-centre Retrospective Cohort Study

Aim

Chemotherapy-induced alopecia (CIA) is the most common side effect of systemic treatment in breast cancer patients. Scalp cooling gained worldwide acceptance in preventing or mitigating CIA in patients undergoing chemotherapy. The objective of this study was to evaluate the efficacy and safety of the Paxman scalp cooling system (PSCS) in Indian breast cancer patients.

Materials and Methods

This is a multi-centre, retrospective-observational study including patients registered from 1st March, 2019 to 30th April, 2021 undergoing chemotherapy for breast cancer by using PSCS. The primary end-point was the incidence of CIA after completing cycles of chemotherapy.

Results

A total of 91 female patients were enrolled in the study, with a median age of 53 years (IQR: 44-62 years). The prevention of alopecia (grade 0 and grade I) was seen in 81%, while more than 50% hair loss (grade 2) was seen in 16.48% after completion of treatment. The univariate analysis results showed that CIA was significantly higher in patients who received anthracyclines (OR: 2.69; 95% CI: 1.04-6.958; P = 0.041) and in patients with a post-infusion cooling time of >150 minutes (OR: 8.409; 95% CI: 2.295-30.787; P = 0.001). The incidence of grade 2 (>50% hair loss) alopecia was 81.3% in patients <6 weeks and was 18.8% at >6 weeks of start of chemotherapy (P < 0.0001). No adverse events were reported in 71.4% of patients, and the most common adverse event was headache (18.7%).

Conclusion

PSCS is an effective and well-tolerated treatment modality for preventing CIA among breast cancer patients undergoing chemotherapy.

Low temperature upregulating HSP70 expression to mitigate the paclitaxel-induced damages in NHEK cell

Scalp cooling is the most approved treatment for preventing chemotherapy-induced alopecia (CIA). However, the protective mechanism of scalp cooling has rarely been reported. The goal of the present study was to study the relationship between paclitaxel concentration and temperature and the inhibitory effect of low temperature on paclitaxel-induced alopecia. The results showed that the dose of paclitaxel should not exceed 60-70 mg/mL during scalp cooling treatment, and the optimal cooling temperature under different paclitaxel concentrations was determined. Normal human epidermal keratinocytes (NHEK) cells were analyzed by global transcriptome analysis, functional annotation and pathway analysis of differentially expressed genes (DEGs) and ELISA kit to analyze the mechanism of low temperature therapy. The expression of HSPA8, HSPA1A and HSPA1B, which belongs to HSP70, was up-regulated by low temperature. These genes are important target genes of low temperature treatment, which were confirmed by ELISA. The up-regulation of PLK2 and the down-regulation of TXNIP expression are the upstream of mitochondrial dysfunction and ROS, inhibiting the accumulation of ROS and up-regulating the mitochondrial membrane potential. Our research partially elucidates the therapeutic mechanism of scalp cooling, which provides a new idea on the drug research and development in CIA.

Malignant neoplasm of the bronchi and lung: Russian clinical guidelines

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Improving preparation for scalp cooling: Learning from women undergoing chemotherapy for early-stage breast cancer-The COOL study

AIMS AND OBJECTIVES

This study set out to understand the experiences and expectations of scalp cooling among women with early-stage breast cancer. The objective was to develop patient co-produced information resources to better inform and prepare women considering scalp cooling during chemotherapy.

BACKGROUND

Treatment-induced alopecia is a common concern among women preparing for chemotherapy. Evidence indicates that many women feel inadequately prepared for scalp cooling, resulting in potentially mitigable distress and disappointment.

DESIGN

A single-site, sequential, explanatory mixed-methods design was used. Participants included women with early-stage breast cancer who had previously or were currently using, scalp cooling. Women completed an online survey exploring scalp cooling experiences and expectations and self-selecting participants took part in one semi-structured, audio-recorded interview. Guidelines for Good Reporting of a Mixed Methods Study were followed.

RESULTS

Forty-nine women (69%) consented to take part in the survey and 23 took part in an interview. Most women described losing more hair than they expected. Many described feeling inadequately prepared for the discomfort of scalp cooling; the additional time needed to accommodate scalp cooling during treatment and, that they lacked information about self- care to help minimise hair loss. Importantly, several participants described variability in nurses' knowledge and practical skills regarding scalp cooling.

CONCLUSIONS

To optimise experience of scalp cooling, women need comprehensive preparatory information about variability in efficacy of scalp cooling; time needed to accommodate scalp cooling; hair care during treatment, and the potential discomfort associated with it. They also need nurses to be confident and well informed about scalp cooling processes.

RELEVANCE TO CLINICAL PRACTICE

Our study led to the development of online, patient co-produced resources to help prepare and inform women considering using scalp cooling; and an online scalp cooling training module and checklist for nurses. Links to the resources are included in the manuscript.

Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022

Disclaimer

This article is based on recommendations from the 12th WALT Congress, Nice, October 3-6, 2018, and a follow-up review of the existing data and the clinical observations of an international multidisciplinary panel of clinicians and researchers with expertise in the area of supportive care in cancer and/or PBM clinical application and dosimetry. This article is informational in nature. As with all clinical materials, this paper should be used with a clear understanding that continued research and practice could result in new insights and recommendations. The review reflects the collective opinion and, as such, does not necessarily represent the opinion of any individual author. In no event shall the authors be liable for any decision made or action taken in reliance on the proposed protocols.

Objective

This position paper reviews the potential prophylactic and therapeutic effects of photobiomodulation (PBM) on side effects of cancer therapy, including chemotherapy (CT), radiation therapy (RT), and hematopoietic stem cell transplantation (HSCT).

Background

There is a considerable body of evidence supporting the efficacy of PBM for preventing oral mucositis (OM) in patients undergoing RT for head and neck cancer (HNC), CT, or HSCT. This could enhance patients’ quality of life, adherence to the prescribed cancer therapy, and treatment outcomes while reducing the cost of cancer care.

Methods

A literature review on PBM effectiveness and dosimetry considerations for managing certain complications of cancer therapy were conducted. A systematic review was conducted when numerous randomized controlled trials were available. Results were presented and discussed at an international consensus meeting at the World Association of photobiomoduLation Therapy (WALT) meeting in 2018 that included world expert oncologists, radiation oncologists, oral oncologists, and oral medicine professionals, physicists, engineers, and oncology researchers. The potential mechanism of action of PBM and evidence of PBM efficacy through reported outcomes for individual indications were assessed.

Results

There is a large body of evidence demonstrating the efficacy of PBM for preventing OM in certain cancer patient populations, as recently outlined by the Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Building on these, the WALT group outlines evidence and prescribed PBM treatment parameters for prophylactic and therapeutic use in supportive care for radiodermatitis, dysphagia, xerostomia, dysgeusia, trismus, mucosal and bone necrosis, lymphedema, hand-foot syndrome, alopecia, oral and dermatologic chronic graft-versus-host disease, voice/speech alterations, peripheral neuropathy, and late fibrosis amongst cancer survivors.

Conclusions

There is robust evidence for using PBM to prevent and treat a broad range of complications in cancer care. Specific clinical practice guidelines or evidence-based expert consensus recommendations are provided. These recommendations are aimed at improving the clinical utilization of PBM therapy in supportive cancer care and promoting research in this field. It is anticipated these guidelines will be revised periodically.

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.

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.

[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.

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.

PI3K Inhibitors and Adverse Events: Optimizing Patient Care for the Treatment of Advanced Breast Cancer

BACKGROUND

Excessive activation of the PI3K pathway has been associated with malignant transformation and resistance to treatment in various cancer types. Various PI3K inhibitors have been evaluated in phase 3 clinical trials; however, most have been associated with modest clinical improvement and poor tolerability. The safety profile of PI3K inhibitors poses new challenges in treatment monitoring and management of common adverse events (AEs).

OBJECTIVES

The purpose of this article is to provide an overview of AEs associated with PI3K inhibitors, with a focus on alpelisib, as well as guidance on the prevention and management of AEs.

METHODS

The literature and results from phase 3 trials evaluating the efficacy and safety of endocrine therapy plus PI3K inhibitors in patients with advanced breast cancer were reviewed.

FINDINGS

AEs associated with PI3K inhibitors include hyperglycemia, diarrhea, nausea, rash, and decreased appetite. Prevention strategies are recommended to avoid the development or decrease the severity of these AEs. Patient education and multidisciplinary care are necessary for the optimal care of these patients.

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.

Extremity Cooling: A Synthesis of Cryotherapy Interventions to Reduce Peripheral Neuropathy and Nail Changes From Taxane-Based Chemotherapy

BACKGROUND

Taxane-based chemotherapies are frequently used to treat solid tumor cancers. Two significant side effects include nail changes and/or peripheral neuropathy. These side effects can cause pain, infections, dose reductions, and treatment delays, all of which negatively affect quality of life.

OBJECTIVES

This article synthesizes the literature on efficacy and tolerability of extremity cryotherapy during taxane administration to identify if it is an intervention that can be provided to patients to mitigate these symptoms.

METHODS

A literature review was performed using PubMed®, the Cochrane Database of Systematic Reviews, Ovid, Web of Science, and CINAHL®. 46 articles were initially identified, and 10 articles were reviewed (5 related to nail changes and 5 related to neuropathy).

FINDINGS

Larger, powered studies are needed on these topics; however, existing data suggest this intervention as a promising low-risk option for mitigating the severity of nail changes and peripheral neuropathy related to taxane chemotherapy.

Photobiomodulation for the management of alopecia: mechanisms of action, patient selection and perspectives

Photobiomodulation (PBM) or low-level laser therapy was discovered over 50 years ago, when Mester in Hungary observed regrowth of hair in mice when irradiated with a ruby laser. At the present time, several different PBM devices are marketed to assist with hair regrowth in alopecia patients. This review covers the three main types of alopecia (androgenetic, areata, and chemotherapy-induced), and discusses the mechanism of action of PBM for each disease. The different devices used (mostly low powered red laser diodes), dosimetry, animal models, and clinical trials are summarized. Criteria for patient selection are outlined. Finally a perspectives section looks forward to the future.

Improving Information Provision on Chemotherapy-Induced Alopecia and Scalp Cooling: A Comprehensive Approach Including A Website and Web-Based Decision Tool

Objective

Alopecia is a frequently occurring side effect of chemotherapy and has high impact on many patients. Currently, scalp cooling is the only method to prevent this chemotherapy-induced alopecia (CIA) and it is effective in about half of the patients. Since determinants of the success are largely unknown, all patients should be prepared for potential hair loss. The objective was to provide up-to-date online information about CIA and scalp cooling to support patients in coping with CIA and in their choice regarding scalp cooling.

Methods

Essential aspects of delivering information and lack of information were identified during focus groups, interviews, and a questionnaire survey among cancer patients, and in discussions with nurses.

Results

The obtained information was used to develop a website (www.scalpcooling.org) and a web-based tool. It combines scientific evidence and practical advice about CIA and regrowth of hair, scalp-cooling tolerance, efficacy and safety, as well as an overview of possible advantages and disadvantages. The web-based tool provides tailored information about the probability of CIA with and without scalp cooling in particular chemotherapy regimens. Besides, the tool offers patients' support in decision-making by allowing them to reflect and consider their values and opinions about scalp cooling.

Conclusions

This comprehensive information is useful during nursing consultations.

Scalp Cooling: Implementation of a Program at a Multisite Organization

BACKGROUND

Chemotherapy-induced alopecia is a well-known side effect of some types of cancer treatments. With U.S. Food and Drug Administration clearance of two scalp cooling machines, patients with cancer now have the opportunity to minimize this hair loss. However, multiple barriers can exist for organizations when establishing a scalp cooling program.

OBJECTIVES

This article describes the experience of a large multisite organization that implemented a machine-based scalp cooling program.

METHODS

Nursing staff led an interprofessional team that addressed components of the program. As a result, eight sites within the authors' organization simultaneously began offering scalp cooling via machine using a single unified process. This approach was then successfully replicated one year later to prepare six additional sites to launch scalp cooling for other solid tumor types beyond breast cancer.

FINDINGS

Using a structured, collaborative, and interprofessional approach to the implementation of a scalp cooling program at the authors' institution allowed for standardization of care across sites. This approach can be replicated at other healthcare institutions.

Prolonging the duration of post-infusion scalp cooling in the prevention of anthracycline-induced alopecia: a randomised trial in patients with breast cancer treated with adjuvant chemotherapy

PURPOSE

Scalp cooling as a method to reduce the incidence of chemotherapy-induced alopecia (CIA) is increasingly used in daily practice worldwide. However, in patients treated with 5-fluorouracil, epirubicin and cyclophosphamide (FEC), scalp cooling fails in 48-67% of patients. This study investigated the efficacy of extended duration of post-infusion scalp cooling in breast cancer patients treated with this regimen.

METHODS

In this prospective multi-centre randomised study, 102 patients with early breast cancer treated with adjuvant FEC chemotherapy were randomly assigned in a 1:1 ratio to a post-infusion cooling time of 90 or 150 min. The primary endpoint was the need to wear a wig or other head covering to mask visible hair loss.

RESULTS

Sixteen out of 48 patients (33%) treated with 90 min of post-infusion cooling did not need any head covering, compared with 21 out of 46 patients (45%) treated with 150 min of post-infusion cooling (p = 0.2). WHO grades 2-3 (moderate-complete) alopecia were reported more often in patients treated with 90-min post-infusion cooling time (n = 25/51 (49%) versus n = 17/51 (33%); p = 0,02). Scalp cooling was well-tolerated (mean Visual Analogue Score 7.4) and only three patients (3%) stopped due to intolerance during treatment.

CONCLUSIONS

Extending the duration of 90-min post-infusion scalp cooling to 150 min in patients treated with adjuvant FEC chemotherapy was well-tolerated but did not significantly diminish the need for head covering. However, grades 2-3 alopecia was seen less often with prolonged post-infusion scalp cooling.