Scalp cooling with adjuvant/neoadjuvant chemotherapy for breast cancer and the risk of scalp metastases: systematic review and meta-analysis

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.

Improving Quality of Life During Chemotherapy: Cannabinoids, Cryotherapy, and Scalp Cooling

There have been significant advances in the treatment of cancer in the past decade. However, patients continue to suffer from significant side effects of antineoplastic agents that greatly affect their quality of life (QOL), including chemotherapy-induced nausea and vomiting (CINV), chemotherapy-induced peripheral neuropathy (CIPN), and chemotherapy-induced alopecia (CIA). This review aims to provide an updated overview of emerging strategies for the management and prevention of these immediate and long-lasting side effects. The use of integrative medicine including cannabis continues to evolve in the realm of CINV and cancer-related anorexia. Although no pharmaceutical agent has been approved for the prevention of CIPN, cryotherapy, compression therapy and, more recently, cryocompression therapy have shown benefit in small trials, but there are concerns with tolerability especially related to cryotherapy. More data are necessary to determine an effective and tolerable option to prevent CIPN in large, randomized studies. Scalp cooling (SC), which has a similar mechanism to cryotherapy and compression therapy for CIPN prevention, has proven to be an effective and tolerable approach in randomized studies and has significantly limited CIA, an entity that definitively affects the QOL of patients living with cancer. Taken together, cannabis, cryotherapy, compression and cryocompression therapy, and SC all strive to improve the QOL of patients living with cancer by minimizing the side effects of chemotherapeutic agents.

Breast cancer with scalp metastases: a case report

BACKGROUND

While breast cancer is the most common cancer in women, cutaneous metastases are rare in breast cancer. Additionally, scalp involvement in breast cancer metastasis is extremely rare. That being said, scalp lesions should always be thoroughly investigated to distinguish metastatic lesions from other neoplasms.

CASE PRESENTATION

A 47-year-old female Middle-Eastern patient presented with metastatic breast cancer in the lungs, bone, liver, and brain with no signs of multiple organ failure, in addition to cutaneous metastases, including the scalp. Between 2017 and 2022, she was managed through modified radical mastectomy, radiotherapy, and several lines of chemotherapy. She presented in September of 2022 with enlarging scalp nodules, which started developing 2 months prior to her presentation. Physical examination revealed firm, non-tender, and immobile skin lesions. Magnetic resonance imaging scan of the head showed soft tissue nodules in different sequences. A punch biopsy was taken from the largest scalp lesion and showed metastatic invasive ductal carcinoma. A panel of immunohistochemistry stains was applied, because a single specific marker for differentiating primary cutaneous adnexal tumors or other malignant neoplasms from breast cancer has not yet been identified. The panel showed positive estrogen receptor 95%, progesterone receptor 5%, negative human epidermal growth factor receptor 2, positive GATA binding protein 3, positive cytokeratin-7, negative P63, and negative KIT (CD117).

CONCLUSION

Breast cancer metastases to the scalp are extremely uncommon. When a scalp metastasis is present, it might be the only symptomatic sign of disease progression or widespread metastatic lesions. However, such lesions warrant a comprehensive radiologic and pathologic workup to rule out other possibilities of skin pathologies, such as sebaceous skin adenocarcinoma as it effects the management plan.

The use of photobiomodulation therapy for the management of chemotherapy-induced alopecia: a randomized, controlled trial (HAIRLASER trial)

PURPOSE

The purpose of this trial was to evaluate if photobiomodulation (PBM) can accelerate hair regrowth after chemotherapy in breast cancer patients and if this is correlated with a better quality of life (QoL).

METHODS

A randomized controlled trial with breast cancer patients that underwent an anthracycline and taxane-containing chemotherapy regimen was set up at the Jessa Hospital (Hasselt, Belgium). Patients were randomized into the control group (no intervention) or the PBM group (three PBM sessions each week for 12 weeks, starting the last day of their chemotherapy). Hair regrowth was evaluated based on photographic assessments. Two blinded researchers independently scored the hair regrowth using a numerical rating scale (NRS). In addition, the QoL was measured using the European Organization for Research and Treatment-QOL questionnaire and Breast Cancer-specific module (EORTC QLQ-C30 and QLQ-BR23). Data were collected on the day of their last chemotherapy session and 1, 2, and 3 months post-chemotherapy.

RESULTS

A total of 32 breast cancer patients were included in the trial between June 2020 and February 2022. Significantly higher NRS scores were observed in the PBM group at 1-month post-chemotherapy compared to baseline, whereas they remained constant in the control group. Patients allocated to the PBM group scored their global health significantly higher at all time points compared to the control.

CONCLUSION

Based on the results of the HAIRLASER trial, PBM seems to accelerate hair regrowth after chemotherapy in breast cancer patients resulting in an improved global health status and better body image. The study was registered in July 2019 at ClinicalTrials.gov (NCT04036994).

[Scalp cooling for the prevention of chemotherapy-induced alopecia: systematic review and meta-analysis.]

OBJECTIVE

Alopecia is one of the most common adverse effects of chemotherapy, having a significant impact on the quality of life of patients who suffer from it. Among the interventions available for its prevention, scalp cooling (SC) is the most widely used. The aim of this study was to assess the efficacy and safety of the use of SC systems during chemotherapy sessions for the prevention or the reduction of the extent of chemotherapy-induced alopecia.

METHODS

A systematic review of the literature published up to November 2021 was carried out. Randomized clinical trials were selected. The main outcome measure was alopecia (hair loss>50%) during and after chemotherapy treatment. When possible, a quantitative synthesis of the results was performed through meta-analysis using the Stata v.15.0 software. The risk ratio (RR) of the variable alopecia, was estimated using a random effects model following the Mantel-Haenszel method. Statistical heterogeneity of the results was evaluated graphically and through the test of heterogeneity χ2 and the Higgins I2 statistic. Sensitivity analyses and subgroup analyses were performed.

RESULTS

13 studies were included, with a total of 832 participants (97.7% women). In most studies, the main chemotherapy treatment applied was anthracyclines or the combination of anthracyclines and taxanes. The results obtained indicate that SC prevents alopecia (loss>50%) by 43% compared to the control group (RR=0.57; 95% CI=0.46 to 0.69; k=9; n=494; I2=63.8%). No statistically significant difference was found between the efficacy of automated and non-automated cooling systems (P=0.967). No serious short- or medium-term adverse events related to SC were recorded.

CONCLUSIONS

The results suggest that scalp cooling contributes to the prevention of chemotherapy-induced alopecia.

Mitigating acute chemotherapy-associated adverse events in patients with cancer

Despite the enthusiasm surrounding novel targeted agents and immunotherapies, chemotherapy remains the mainstay treatment for most human malignancies, either alone or in combination. Yet, the burden of chemotherapy-associated adverse events (CAAEs) remains high and, importantly, is associated with considerable morbidity, mortality and costs that affect patients across multiple dimensions, including physical, emotional and social functioning. CAAEs can directly affect patient outcomes and indirectly increase the risk of cancer recurrence by compromising treatment intensity and continuity. Systematic efforts to identify and critically summarize the evidence on management approaches for CAAEs remain limited. Herein, we review the most common acute CAAEs having a major effect on survival, quality of life, function and/or continuation of optimal therapy. We focus on selected acute toxicities that occur during treatment, summarizing their underlying pathophysiology, multifactorial aetiologies, evidenced-based treatments, prevention strategies and management recommendations. We also summarize the available evidence on risk factors, validated risk assessment tools and other efforts to optimize symptom control in patients most likely to benefit in order to personalize the prevention and treatment of acute CAAEs. Finally, we discuss innovative symptom monitoring and supportive care interventions that are under development to further improve the outcomes of patients with cancer.

Hair safe study: Effects of scalp cooling on hair preservation and hair regrowth in breast cancer patients receiving chemotherapy - A prospective interventional study

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Scalp cooling significantly reduced chemotherapy-induced-alopecia in breast cancer patients.

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No significant effect regarding regrowth after chemotherapy in scalp cooling group.

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Scalp cooling is more effective in preventing alopecia in patients receiving taxane monotherapy.

Comparable effectiveness of 45- and 20-min post-infusion scalp cooling time in preventing paclitaxel-induced alopecia - a randomized controlled trial

Purpose

Scalp cooling can prevent chemotherapy-induced alopecia (CIA). Previously, the post-infusion cooling time (PICT) could be successfully reduced in docetaxel-treated patients from 90 to 45 and 20 min. Therefore, it seems plausible that the PICT can be shortened for paclitaxel-treated patients as well.

Methods

Patients treated with weekly paclitaxel were included in this multi-centre trial and randomly assigned to a PICT of 45 or 20 min. The results were compared to a standard PICT of 90 min, derived from prospective collected data from the Dutch Scalp Cooling Registry. The primary endpoint was the percentage of patients who decide to not wear a wig or head covering. Secondary endpoints were the degree of CIA assessed with the Dean scale for assessment of hair loss; alopecia graded according to NCI CTC toxicity version 4.03 (CTCAE4.03); tolerance of scalp cooling and perceived distress of CIA.

Results

Ninety-one patients were enrolled in this study; 74 patients were evaluable for hair loss. Hair preservation was successful in 27 patients (75%) with a PICT of 45 min and in 31 patients (82%) with a PICT of 20 min. There was no difference in success rate with the standard PICT of 90 min (85%, p = 0.29). Similar success rates were seen when using the Dean scale and CTCAE assessment, with no differences between groups (p = 0.12 and p = 0.38).

Conclusions

A 20 min PICT is as effective as 45 and 90 min to prevent weekly paclitaxel-induced alopecia and should be the new standard of care.

Trial register

ClinicalTrials.gov Identifier: NCT03266185.

Scalp Cooling for Prevention of Chemotherapy-Induced Alopecia for Women and Men with Various Cancer Entities: A Two-Years Survey of an Outpatient Cancer Center in Germany

Introduction: the aim of this survey was to assess the efficacy and the feasibility of scalp cooling in an outpatient hematological and oncological center in a real-world setting. Methods: we prospectively monitored cancer patients from august 2017 to october 2019 receiving oncological treatments with scalp cooling, using the sensor-controlled system „DigniCap“. Effectiveness was defined by a self-estimated hair loss < Grad 2 (<50%) according to the Common terminology Criteria for adverse events V4.0 or not requiring a wig. Withdrawal from scalp cooling on patient´s demand was considered as failure. Tolerability and safety were also evaluated. Results: 94 patients with chemotherapy for their primary (52%) or metastatic (48%) disease had a total of 634 scalp cooling sessions. Scalp cooling was well accepted with increasing experience of the nurses (withdrawal for any reason 29/94). Among the female population (N=85) 54% received a (neo-) adjuvant chemotherapy. 48% received a taxan-based therapy, 35% anthracycline-based; 17% platin compounds and others. The overall success rate in the female sample was 72%. In the male group (N=9) the majority had a metastatic disease (6/9) and received a taxan-based therapy (5/9). The rate of withdrawal by discomfort and pain was high and the success rate was 44%. Conclusion: Our study confirms the satisfaction of patients with scalp cooling to prevent chemotherapy-induced alopecia. Scalp cooling increases acceptance of the recommendation and administration of chemotherapy and decreases the degree of distress of patients and their treating physicians. Reimbursement remains a major issue in the out-patient setting.

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.

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

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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.

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.

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.

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.

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.

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.

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.

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.

An Unusual Case of Scalp Metastasis from Breast Cancer

BACKGROUND

The most common sites of breast cancer metastases are the bone, lung, liver, and brain. Scalp involvement in breast cancer metastasis is extraordinarily rare.

CASE DESCRIPTION

This study reports a 52-year-old woman who had a history of malignant right breast cancer and underwent a mastectomy. Positron emission tomography/computed tomography revealed a soft tissue nodule measuring 1 × 0.7 cm located subcutaneously on the top left side of the scalp. A scalp mass excision operation was performed with an extended "S"-shaped incision, and the mass was sent for pathology. Immunohistochemistry showed the following results: CK7: +; ER: 2+, 90%; GATA3: +; GCDFP-15: scattered cells+; mammaglobin: -, napsin A: -; and TTF-1: -. These results were consistent with the characteristics of primary right breast cancer, supporting scalp metastasis from breast cancer.

CONCLUSIONS

Scalp metastasis from breast cancer is an exceedingly infrequent phenomenon. Close attention should be paid to soft tissue masses in patients with a healthy appearance and in those with a history of malignant cancer. When neurosurgeons operate on the mass, the circumscription and depth of the tumor must be given further attention.

"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.

Hair regrowth using a properly fitted scalp cooling cap during adjuvant chemotherapy for breast cancer

Patients with breast cancer desire to avoid chemotherapy-induced alopecia because it induces mental stress during treatment. Scalp cooling can suppress chemotherapy-induced alopecia without increasing the risk of scalp metastasis; however, in certain cases, alopecia cannot be prevented. The use of properly fitted scalp cooling caps has not yet been explored in Asian patients. Here, we report a case of hair regrowth using a properly fitted scalp cooling cap during adjuvant chemotherapy for breast cancer. A 51-year-old Japanese woman who was recalled by screening mammography for grouped amorphous calcifications and architectural distortion visited our hospital. Preoperative diagnosis was cT2N0M0 cStage IIA. Sentinel lymph node biopsy revealed axillary metastasis; hence, left mastectomy and axillary lymph node resection were performed. Pathological diagnosis revealed ER/PgR-positive and HER2-negative invasive lobular carcinoma (pT3N2M0 pStage IIIA). Adjuvant chemotherapy comprising four cycles of docetaxel every 3 weeks as well as four cycles of FEC every 3 weeks was performed with scalp cooling. After the first cycle of docetaxel, a 10-cm oval hair loss patch was observed at the vertex of the patient's head. Assuming the scalp cooling cap was not efficiently in contact with the vertex of the patient's head, we modified and properly fit the scalp cooling cap. After the third cycle of docetaxel, hair regrowth at the vertex began and gradually increased during chemotherapy. The patient did not require hair wigs during and after adjuvant chemotherapy. The scalp cooling cap should be carefully fitted at the vertex of the head, which is difficult to be covered, particularly in the case of Japanese patients. In addition, further development of properly fitted scalp cooling caps suitable for various individuals is necessary.

Efficacy of Scalp Cooling in Preventing and Recovering From Chemotherapy-Induced Alopecia in Breast Cancer Patients: The HOPE Study

Purpose: This study aimed to assess the efficacy of scalp-cooling devices in preventing chemotherapy-induced alopecia in Japanese breast cancer patients and investigate whether a scalp-cooling device improves hair volume recovery over a 12 weeks period after completing chemotherapy. Methods: This multicenter controlled trial included women with breast cancer undergoing chemotherapy in Japan between February 2016 and March 2018. The primary endpoint was the proportion of patients with no alopecia at the end of chemotherapy. The secondary endpoint included hair volume at 12 weeks after completing chemotherapy. Results: A total of 48 patients were enrolled; of them, 34 and 14 were sequentially allocated to the scalp-cooling group using the Paxman Hair Loss Prevention System and the control group, respectively. There was no significant difference in average age between the scalp-cooling and the control groups (50.0 ± 9.6 vs. 49.0 ± 9.0 years). More than 50% of patients in each group had stage II breast cancer (scalp-cooling group: 53.1%; control group: 64.3%), more than 90% received adjuvant chemotherapy (scalp-cooling group: 96.9%; control group: 92.9%), and more than 60% were treated with a docetaxel/cyclophosphamide regimen (scalp-cooling group: 75.0%; control group: 64.3%). There were more patients judged to have no alopecia at the end of chemotherapy in the scalp-cooling group than in the control group (26.7% [8/30] vs. 0% [0/13]; P = 0.011). The proportion of patients with alopecia who experienced an increase in hair volume of ≥50% within 12 weeks duration after chemotherapy was 85.7% (24/28) in the scalp-cooling group and 50.0% (6/12) in the control group. No patient developed serious adverse events related to the scalp-cooling device. Conclusions: The use of a scalp-cooling device prevented alopecia with acceptable safety for Japanese patients. In addition, scalp cooling resulted in faster recovery of hair volume after chemotherapy, even in patients for whom scalp cooling failed to prevent chemotherapy-induced alopecia.

AGO Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2019

Every year the Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group, AGO), a group of gynecological oncologists specialized in breast cancer and interdisciplinary members specialized in pathology, radiologic diagnostics, medical oncology, and radiation oncology, prepares and updates evidence-based recommendations for the diagnosis and treatment of patients with early and metastatic breast cancer. Every update is performed according to a documented rule-fixed algorithm, by thoroughly reviewing and scoring the recent publications for their scientific validity and clinical relevance. This current publication presents the 2019 update on the recommendations for metastatic breast cancer.

EVA-Scalp: Evaluation of Patient Satisfaction with a Scalp Cooling Device to Prevent Chemotherapy-Induced Alopecia in Breast Cancer Patients

Purpose

Scalp cooling (SC) offers a chance to reduce hair loss (HL), but patient satisfaction, the effect on well-being, as well as patient selection criteria have not been sufficiently assessed yet.

Methods

In the EVAScalp trial, SC was offered to 70 breast cancer patients who received chemotherapy between November 2015 and September 2018. For SC, the Paxman-Orbis-II System was used. Satisfaction was measured by a questionnaire evaluating the level of depression with the WHO-5 well-being index (WHO-5) plus questions addressing the patient's experiences and side effects using the SC device. To evaluate efficacy, documentation by photo, by a physician, and by an HL-diary was conducted.

Results

Regarding efficacy, a significant difference between chemotherapy regimens is seen. Anthracycline-based therapies led to a stop of SC in 71% of the patients, whereas taxane-based therapies without anthracyclines were associated with a high acceptance of SC, and 88% of patients with paclitaxel-based therapies continued SC throughout their chemotherapy. Overall, only 7.69% of the patients stopped because of side effects. As an indicator for quality of life, WHO-5 was higher (65.8%) in patients with successful SC compared to in patients who stopped SC because of HL or side effects (only 53.0%). The majority of patients (82.22%) with successful SC would recommend SC to other patients.

Conclusions

Patients tolerated SC as long as HL was successfully prevented. The well-being of patients with successful SC was significantly higher than that of patients who stopped SC prematurely. In general, SC is a promising approach and improves patient well-being, but there are still limitations to its utility depending on the chemotherapy regimen used.

Trichoscopy of Scalp Metastases

A 69-year-old woman with invasive ductal breast cancer (BC) presented multiple asymptomatic alopecic areas of the scalp. Trichoscopy revealed peripheral black dots (BDs) and an atypical vascular pattern. Histopathology confirmed the diagnosis of BC metastases. Cutaneous and scalp metastases are a possible sign of advanced and widespread BC, and the diagnosis may be challenging. The trichoscopy of scalp metastases has never been described. BDs and an atypical vascular pattern in our case were a diagnostic clue.

Scalp Cooling: A Patient's Experience

CASE STUDY Ms. X is a 23-year-old female who presented to clinic with stage 2A endometrial cancer of the ovary. At her first visit, Ms. X was prescribed paclitaxel and carboplatin on day 1 for 6 cycles. During the visit, the nurse noted Ms. X could not keep her hands out of her hair; she continually played with it. The nurse, judging by Ms. X's body language, suspected she valued her hair. Ms. X revealed she had been doing some research and wanted to use a cold cap to try and prevent alopecia during her treatment. On the first day of chemotherapy, Ms. X came to the clinic with her mother. They brought a manual cap for scalp cooling and a cooler of dry ice. Her mother was to serve as a "capper" and change the cap at 20- to 30-minute intervals during treatment to keep her scalp cool. Ms. X was made comfortable in an infusion bed, and the cap was applied 30 minutes prior to the start of therapy. Ms. X's mother changed the dry ice caps every 20 minutes throughout the infusion. Ms. X then left it on for 90 minutes following her chemotherapy. After 6 cycles of chemotherapy, Ms. X still had all her hair. She appeared to have retained 100% of her hair, although she estimates that she lost about 5% of her hair. During therapy, she followed the instructions outlined in Table 1. Ms. X reported that she rented the cap for $500 per month and paid $45 per week for the dry ice. Her mother also had to miss work to be the "capper," and this added to the out-of-pocket costs of scalp cooling.

The efficacy and tolerability of scalp cooling in preventing chemotherapy-induced alopecia in patients with breast cancer receiving anthracycline and taxane-based chemotherapy in an Asian setting

BACKGROUND

Scalp cooling has been shown in several studies to be an effective method in preventing chemotherapy-induced alopecia (CIA). Data on the use of scalp cooling in Asian countries are limited, and evidence for its use and efficacy among our patients are not available.

OBJECTIVE

The aim of this study was to assess the effectiveness and tolerability of scalp cooling among breast cancer patients in our study population.

METHODS

Consecutive breast cancer patients receiving FE₇₅C, FE₁₀₀C, FE₁₀₀C-D, docetaxel₇₅ or docetaxel, and cyclophosphamide (TC) at our treatment center were recruited and allocated to the treatment (scalp cooling, DigniCapTM system) or control group in this prospective nonrandomized controlled study. The assessment of alopecia was carried out using the World Health Organization grading system and clinical photographs.

RESULTS

Seventy patients were recruited, but only 25 completed the study and were evaluable for analysis. Five of 12 patients (42%) in the scalp cooling group managed to preserve hair. Two of three patients who received FE₇₅C and TC regimens had minimal hair loss. All patients treated with FE₁₀₀C had severe hair loss. Half of all patients who received scalp cooling throughout chemotherapy rated the treatment as reasonably well tolerated. The most common reason for discontinuing scalp cooling was intolerance to its side effects.

CONCLUSION

Scalp cooling is potentially effective in reducing CIA caused by docetaxel, TC, and FE₇₅C chemotherapy regimen. However, it was not well tolerated by our study population. The dropout rate was high, and this needs to be taken into consideration when pursuing further trials in a similar setting.

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 in Daily Clinical Practice for Breast Cancer Patients Undergoing Curative Chemotherapy: A Multicenter Interventional Study

Objective:

Chemotherapy-induced alopecia is a common and distressful side effect, especially among breast cancer patients. Scalp cooling (SC) can reduce hair loss during anthracycline- and taxane-based chemotherapy. This study assessed the effectiveness of SC in daily clinical practice in three Italian oncology units.

Methods:

From 2014 to 2016, we prospectively included 220 female early-stage breast cancer patients undergoing curative chemotherapy in combination with SC using the Paxman device. Effectiveness was defined as the severity of hair loss according to the Common Terminology Criteria for Adverse Events Version 4.0 as follows: Grade 0, no hair loss; Grade 1, <50% hair loss not requiring a wig; and Grade 2, ≥50% hair loss at each cycle and at completion of chemotherapy. The tolerability and safety were also evaluated.

Results:

The overall success rate of SC (hair loss Grade 0–1) was 68%. Severe hair loss was avoided in 89% of women receiving taxane-based chemotherapy and in 78% of women receiving both anthracyclines and taxanes. Among women undergoing anthracycline-based chemotherapy, 47% experienced hair preservation. SC was well tolerated, as only 20 patients discontinued SC for reasons other than hair loss.

Conclusions:

Our study confirmed that SC provides a reliable chance for breast cancer patients to keep their hair during taxane- and/or anthracycline-based chemotherapy.

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.

Thermal modelling of controlled scalp hypothermia using a thermoelectric cooling cap

This study presents a novel, thermoelectric cryotherapy cap that aims to provide effective and controlled scalp cooling to prevent hair loss for chemotherapy patients. The cap's design consists of multiple thermoelectric coolers (TECs) evenly spaced and bonded to a soft thermal interface material, tightly fitted to a patient's head. A numerical model is developed to assess the performance of alternative cap designs in relation to their ability to achieve hair follicle hypothermia. Under ideal conditions, 26.5 W of heat removal from the scalp is required to achieve the clinically-significant follicle temperature target of 22 °C. Temperature maps of the subcutaneous tissue are generated to visualise the development of hypothermic follicles, and thereby assess the effectiveness of the cap design. Transient studies show that cooling to the therapeutic temperature can be achieved within 40 min. To avoid the possibility of cold-induced tissue damage, individual thermoelectric cooling modules should not be operated at a cooling flux beyond approximately 3175 W/m². This may be achieved with 38 modules evenly spaced in a checkerboard arrangement, each providing 0.7 W of cooling to the scalp.

Persistent major alopecia following adjuvant docetaxel for breast cancer: incidence, characteristics, and prevention with scalp cooling

Background

Persistent alopecia (PA) after docetaxel has been recently described. The aim of our study is to establish the incidence and characteristics of PA following adjuvant docetaxel for breast cancer (BC) and to test the ability of scalp cooling in prevention.

Patients and methods

BC patients receiving adjuvant chemotherapy followed or not by endocrine therapy (and a control group receiving only endocrine therapy) were interviewed in a single institution at 1.5 to 5 years following primary diagnosis searching for PA. A confirmatory prevalence study was later performed in other two institutions. Finally, a prevention study using prophylactic scalp cooling (PSC) with ELASTO-GEL hypothermia caps in patients receiving adjuvant docetaxel was performed.

Results

In the initial prevalence study (492 patients), minor forms of PA (grade 1) were recorded with all chemotherapy regimens and aromatase inhibitors. Patients receiving docetaxel regimens at cumulative dose (CD) ≥ 400 mmg/m² presented a significantly higher prevalence of grades 1 PA (33–52%) and 2 PA (5–12%). Prevalence of grade 2 PA with docetaxel CD ≥ 400 mmg/m² was confirmed in two other institutions. Overall, grade 2 PA was seen in 10.06% (95% CI 7.36–13.61) of 358 patients with docetaxel regimens reaching CD ≥ 400 mmg/m², but not in patients with lower docetaxel CD, other chemotherapy regimens, or endocrine therapy alone. In prevention trial, no grade 2 PA occurred among 116 patients receiving adjuvant docetaxel (≥ 400 mmg/m²) and PSC followed-up after a 96 months median time. PSC was well tolerated. No scalp relapses were seen among 30 patients (22% of all inclusions) having disease relapse.

Conclusion

Adjuvant treatment with docetaxel (CD ≥ 400 mmg/m²) is associated with a significant rate of grade 2 PA, leading to wearing a wig, in around 10% of patients. This toxicity was completely prevented with scalp cooling. Clinical Trial Reference: NCT00515762.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4855-2) contains supplementary material, which is available to authorized users.

Hair disorders in cancer survivors

With increasing survival rates across all cancers, survivors represent a growing population that is frequently affected by persistent or permanent hair growth disorders as a result of systemic therapies, radiotherapy, surgical procedures, and therapeutic transplants. These hair disorders include persistent chemotherapy-induced alopecia, persistent radiotherapy-induced alopecia, endocrine therapy-induced alopecia and hirsutism, postsurgery alopecia and localized hypertrichosis, and persistent stem cell transplantation and targeted therapy-induced alopecia. The information contained in this continuing medical education series should facilitate a better understanding on hair disorders in cancer survivors so that adequate support and therapies may be provided.

Hair disorders in patients with cancer

Cytotoxic chemotherapies, molecularly targeted therapies, immunotherapies, radiotherapy, stem cell transplants, and endocrine therapies may lead to hair disorders, including alopecia, hirsutism, hypertrichosis, and pigmentary and textural hair changes. The mechanisms underlying these changes are varied and remain incompletely understood, hampering the development of preventive or therapeutic guidelines. The psychosocial impact of chemotherapy-induced alopecia has been well documented primarily in the oncology literature; however, the effect of other alterations, such as radiation-induced alopecia, hirsutism, and changes in hair color or texture on quality of life have not been described. This article reviews clinically significant therapy-related hair disorders in oncology patients, including the underlying pathophysiological mechanisms, severity grading scales, patient-reported quality of life questionnaires, management strategies, and future translational research opportunities.

Scalp cooling successfully prevents alopecia in breast cancer patients undergoing anthracycline/taxane-based chemotherapy

INTRODUCTION

Chemotherapy for breast cancer induces alopecia, representing a major source of patient distress. This study assesses whether a scalp-cooling device is effective in reducing chemotherapy-induced alopecia, and assesses adverse treatment effects.

MATERIALS AND METHODS

A prospective observational study including women with breast cancer undergoing chemotherapy and scalp cooling using a Paxman device. The primary efficacy end points were: successful hair preservation (no hair loss; <30% hair loss not requiring a wig; or <50% hair loss not requiring a wig) at the completion of chemotherapy. Secondary end points included adverse effects such as headache, pain, nausea or dizziness.

RESULTS

The study enrolled 131 participants. Mean patient age was 49.8 years; 74% received anthracycline/taxane-based chemotherapy and 26% received taxane-monotherapy based chemotherapy. Hair preservation was successful in 102 women who underwent scalp cooling (71.0%; 95% CI = 63-79%). Only adverse events related to device use were collected, representing 7% (95% CI = 3-11%) of cases.

CONCLUSIONS

Scalp cooling is effective in preventing hair loss among breast cancer patients undergoing standard chemotherapy treatment, and has minimal adverse effects.