Scalp cooling to prevent alopecia after chemotherapy can be considered safe in patients with breast cancer

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.

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 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.

"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.

Preventing chemotherapy-induced alopecia: a prospective clinical trial on the efficacy and safety of a scalp-cooling system in early breast cancer patients treated with anthracyclines

Background

Chemotherapy-induced alopecia (CIA) is a distressing side effect of cancer therapy. The trial aimed to assess feasibility and effectiveness of scalp-cooling system DigniCap® to prevent CIA in primary breast cancer patients receiving an anthracycline containing adjuvant chemotherapy (CT).

Methods

Hair loss (HL) was evaluated by patient self-assessment and by the physician according to the Dean’s scale at baseline and after each cycle of CT. The primary efficacy endpoint was the patient self-assessment HL score evaluated at least 3 weeks after completing CT. A Dean's scale score of 0–2 (i.e. HL ≤50%) was considered a success.

Results

From July 2014 to November 2016, 139 consecutive breast cancer patients were enrolled and received at least one treatment with scalp cooling. Fifty-six out of 131 evaluated patients successfully prevented HL (43%, 95% CI: 34–51%). Twenty-four patients (32%) discontinued the scalp cooling because of alopecia or scalp-cooling related AE, three patients had missing information on CIA, and 48 patients (64%) had a HL greater than 50% after CT. No serious AEs were reported.

Conclusions

DigniCap® System resulted as a promising medical device to be safely integrated in supportive care of early breast cancer patients. Longer follow-up is needed to assess long-term safety and feasibility.

Clinical trial registration number

NCT03712696.

Hair Loss Prevention by a Scalp Cooling Device in Early Breast Cancer Patients: The Poliambulanza Preliminary Experience

BACKGROUND

The most effective agents in the treatment of breast cancer have a common side effect, the hair loss. Some studies reported a reduction of hair loss with the use of the scalp cooling device. Indeed, it decreases the drug accumulation in the hair follicles. We report our preliminary experience with a scalp cooling device in reducing chemotherapy-induced alopecia and related distress in breast cancer patients undergoing adjuvant chemotherapy.

METHODS

Hair loss grading and treatment tolerability were evaluated during chemotherapy every 21 days and 3 weeks after the last cycle of chemotherapy via Dean's scale by patients and operators and a comfort analogic scale by patients. We administered the Hospital Anxiety and Depression Scale questionnaire at the baseline and at the end of treatment to assess the distress related to chemotherapy- induced alopecia.

RESULTS

Among the 46 patients identified, 27 accepted the device. The eligible chemotherapy regimens included docetaxel+cyclophosphamide (TC), doxorubicin+cyclophosphamide (AC) and paclitaxel (P) weekly+trastuzumab (T). 24 pts (89%) completed the treatment; 3 pts (11%) treated with AC prematurely interrupted use of the scalp-cooling device due to inefficacy. After the last cycle of chemotherapy, the number of patient who perceived a HL < grade 2 was 16 (59%). The hair retention reported by operators has been higher (78%). 81.5% of patients well tolerated the treatment.

CONCLUSION

In our study, the scalp-cooling device reduced chemotherapy-induced alopecia in taxane- based chemotherapy. Furthermore, it suggests a discordance in hair loss perception between patients and operators.

Alopecia in Association with Malignancy: A Review

The interaction between hair and malignancy is complicated. Various hair abnormalities can manifest in oncology patients as a clinical manifestation, the result of cancer therapy, or due to a paraneoplastic condition. The mechanisms of these changes remain unclear. Alopecia is one of the common clinical presentations occurring in oncology patients that affects their quality of life. The condition can concomitantly develop during the course of malignancy or when patients undergo cancer treatment. It is important for physicians to understand alopecia in association with malignancy as it may be an important associated finding or provide the clues to aid diagnosis. The aim of this review is to summarize the clinical characteristics of alopecia that occur in cancer patients and their relationship with the type of malignancy and its treatment.

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.

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

PURPOSE

The risk of scalp metastases in patients using scalp cooling for preservation of hair during chemotherapy has been a concern but is poorly described.

METHODS

A systematic review and meta-analysis of longitudinal studies was undertaken to evaluate the effect of scalp cooling versus no scalp cooling on the risk of scalp metastasis in patients treated for breast cancer with chemotherapy. Electronic databases, journal specific, and hand searches of articles identified were searched. Patients were matched based on disease, treatment, lack of metastatic disease, and sex.

RESULTS

A total of 24 full-text articles were identified for review. Of these articles, ten quantified the incidence of scalp metastasis with scalp cooling over time. For scalp cooling, 1959 patients were evaluated over an estimated mean time frame of 43.1 months. For no scalp cooling, 1238 patients were evaluated over an estimated mean time frame of 87.4 months. The incidence rate of scalp metastasis in the scalp cooling group versus the no scalp cooling group was 0.61% (95% CI 0.32-1.1%) versus 0.41% (95% CI 0.13-0.94%); P = 0.43.

CONCLUSION

The incidence of scalp metastases was low regardless of scalp cooling. This analysis suggests that scalp cooling does not increase the incidence of scalp metastases.

Association Between Use of a Scalp Cooling Device and Alopecia After Chemotherapy for Breast Cancer

IMPORTANCE

Chemotherapy-induced alopecia is a common and distressing adverse effect. In previous studies of scalp cooling to prevent chemotherapy-induced alopecia, conclusions have been limited.

OBJECTIVES

To evaluate whether use of a scalp cooling system is associated with a lower amount of hair loss among women receiving specific chemotherapy regimens for early-stage breast cancer and to assess related changes in quality of life.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study conducted at 5 US medical centers of women with stage I or II breast cancer receiving adjuvant or neoadjuvant chemotherapy regimens excluding sequential or combination anthracycline and taxane (106 patients in the scalp cooling group and 16 in the control group; 14 matched by both age and chemotherapy regimen). The study was conducted between August 2013 and October 2014 with ongoing annual follow-up for 5 years.

EXPOSURES

Use of a scalp cooling system. Scalp cooling was initiated 30 minutes prior to each chemotherapy cycle, with scalp temperature maintained at 3°C (37°F) throughout chemotherapy and for 90 minutes to 120 minutes afterward.

MAIN OUTCOMES AND MEASURES

Self-estimated hair loss using the Dean scale was assessed 4 weeks after the last dose of chemotherapy by unblinded patient review of 5 photographs. A Dean scale score of 0 to 2 (≤50% hair loss) was defined as treatment success. A positive association between scalp cooling and reduced risk of hair loss would be demonstrated if 50% or more of patients in the scalp cooling group achieved treatment success, with the lower bound of the 95% CI greater than 40% of the success proportion. Quality of life was assessed at baseline, at the start of the last chemotherapy cycle, and 1 month later. Median follow-up was 29.5 months.

RESULTS

Among the 122 patients in the study, the mean age was 53 years (range, 28-77 years); 77.0% were white, 9.0% were black, and 10.7% were Asian; and the mean duration of chemotherapy was 2.3 months (median, 2.1 months). No participants in the scalp cooling group received anthracyclines. Hair loss of 50% or less (Dean score of 0-2) was seen in 67 of 101 patients (66.3%; 95% CI, 56.2%-75.4%) evaluable for alopecia in the scalp cooling group vs 0 of 16 patients (0%) in the control group (P < .001). Three of 5 quality-of-life measures were significantly better 1 month after the end of chemotherapy in the scalp cooling group. Of patients who underwent scalp cooling, 27.3% (95% CI, 18.0%-36.6%) reported feeling less physically attractive compared with 56.3% (95% CI, 31.9%-80.6%) of patients in the control group (P = .02). Of the 106 patients in the scalp cooling group, 4 (3.8%) experienced the adverse event of mild headache and 3 (2.8%) discontinued scalp cooling due to feeling cold.

CONCLUSIONS AND RELEVANCE

Among women undergoing non-anthracycline-based adjuvant chemotherapy for early-stage breast cancer, the use of scalp cooling vs no scalp cooling was associated with less hair loss at 4 weeks after the last dose of chemotherapy. Further research is needed to assess outcomes after patients receive anthracycline regimens, longer-term measures of alopecia, and adverse effects.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01831024.

The use of scalp cooling for chemotherapy-induced hair loss

Chemotherapy-induced hair loss is a common and distressing side effect of cancer therapy and is one of the major unmet challenges in cancer management. Scalp cooling can prevent chemotherapy-induced hair loss in some cancer patients with solid tumours receiving certain chemotherapy regimens. Recent evidence indicates that this technique does not increase the risk of scalp metastasis. A reduction in post-chemotherapy infusion duration of scalp cooling and the advancement in cool cap technology may assist clinicians in promoting scalp cooling to cancer patients. This article discusses recent research, scalp cooling guidelines, products available and implications for nurses and their organisations in providing scalp cooling. It also considers recent advancements in identifying genes associated with chemotherapy-induced hair loss and international research collaborations including a registry and a 'chemotherapy-induced hair loss action group'--all striving to improve the patient experience of chemotherapy-induced hair loss.

Familiarity, opinions, experiences and knowledge about scalp cooling: a Dutch survey among breast cancer patients and oncological professionals

Objective:

Scalp cooling (SC) is applied to reduce chemotherapy-induced alopecia (CIA). The aim of this study was to investigate patients’ familiarity and opinions and oncological professionals’ attitude and knowledge about SC in the Netherlands.

Methods:

Ex breast cancer patients, nurses and medical oncologists (MDs) from SC and non-SC hospitals filled out questionnaires.

Results:

The majority of MDs and nurses were satisfied with the results of SC, as were SC patients. Over 33% of MDs and nurses perceived their knowledge level insufficient to inform patients about effectiveness, which was over 43% for information about safety. MDs main reason to not apply SC was doubt about effectiveness and safety. Nurses generally offered SC to a minority of eligible patients. Patients were frequently unfamiliar with SC before diagnosis. Seventy percent of SC patients with insufficient results (20/52) reported to mind it very much. With expected success rates of 35% and 50%, respectively, 36% and 54% of patients would use SC again.

Conclusion:

Room for improvement has been shown for both patients’ familiarity and oncological professionals’ knowledge about SC. Sharing knowledge about results, safety and patients’ experiences will improve patient counseling and SC availability. The results of this survey led to the development of a national standard on CIA and SC.

Scalp cooling: management option for chemotherapy-induced alopecia

Chemotherapy is increasingly being administered as a treatment for cancer and with it are a number of possible side effects. One, which has a negative impact on a patient's quality of life and their self-esteem, is that of chemotherapy-induced alopecia (CIA). A side effect of which, for some, could be prevented by the use of scalp cooling, dependent on the regimen being administered and patient choice. This article explores the issue of CIA from the patient's perspective and scalp cooling as a preventative measure, along with a review of the evidence around the risk associated with developing scalp metastases following scalp cooling. It also discusses why scalp cooling should be available for both male and female patients; along with the potential impact scalp cooling may have on clinical areas delivering chemotherapy.