Digest Commentator: Keith Wilson, PhD, CPsych. Emeritus Clinician Investigator, Clinical Epidemiology Program, Ottawa Hospital Research Institute
Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto
For most women undergoing chemotherapy for breast cancer, hair loss (alopecia) is a distressing side effect of treatment. It has been known for some time that cooling the scalp during chemotherapy sessions can reduce the extent of alopecia in some people. The mechanism seems to be that cooling the scalp reduces blood flow – and the corresponding delivery of toxic chemotherapy drugs – to the sensitive hair follicles. Commercial cooling machines have been developed, and are available for use in some centres. To date, however, the efficacy of scalp cooling for preventing chemotherapy-induced alopecia has never been evaluated in a large randomized controlled trial.
Nangia et al (2017) conducted a multi-centre study of 182 women with Stage I-II breast cancer who were receiving adjunct taxane-based or anthracycline-based chemotherapy which typically cause marked alopecia. Participants were assigned randomly to a scalp-cooling protocol or to a control group that did not receive scalp cooling. The cooling protocol required patients to wear a helmet-like cap for 30 minutes before each chemotherapy session, during the session, and for 90 minutes after. A liquid coolant was circulated through the cap to reduce scalp temperature. The primary outcome for hair preservation was a standard grading system, in which a clinician rated the extent of the patient’s hair loss.
The authors reported that 142 patients, 95 in the cooling group and 47 in the control were evaluable in a planned interim analysis. Of the 95 patients who received the cooling protocol, 5% had no hair loss at all, and a further 45% had <50% loss: an overall response rate of 50%. None of the control participants achieved that degree of hair preservation. Furthermore, all of the control participants went on to wear a wig or head wrap in their daily lives, whereas 37% of the treatment group felt no need to do so.
This study also examined whether broad domains of quality of life were improved with the scalp cooling intervention, but there was no evidence that depression, anxiety, or social functioning were different between the two groups. It was also noted that different sites of the multi-centre trial had different success rates; apparently, there are technical issues involved in fitting the cooling caps that require training. Interestingly, however, a companion article in the same issue of JAMA reported that in routine use, up to 66% of patients can be helped with this approach.
Why I liked this article: There are individual differences in how people respond to chemotherapy-induced alopecia. Some women embrace their hair loss, some accept it with resignation, and others feel stigmatized. The value of scalp cooling in reducing this troubling side effect seems to be underestimated. As with most novel interventions, there are unanswered questions – including who will pay the estimated $2000 to $4000 cost per patient. Concurrent scalp cooling during a chemotherapy session can also be quite uncomfortable for some individuals. In general, however, it is remarkable that a cosmetically meaningful reduction in alopecia can be achieved in about 50% of women who are receiving chemotherapy for breast cancer, using such a low-tech concept. That’s pretty cool.
Article. Nangia, J., Wang, T., Osborne, C., Niravath, P., Otte, K., Papish, S., Holmes, F., Abraham, J., Lacouture, M., Courtwright, J., Paxman, R., Rude, M., Hilsenbeck, S., Osborne, C.K., & Rimawi, M. (2017). Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: the SCALP randomized clinical trial. Journal of the American Medical Association, 317, 596-605. doi:10.1001/jama.2016.20939
Journal website: http://jamanetwork.com/
Dr. Morris’ university webpage: http://surgery.med.umich.edu/general/patient/faculty/ammsurg.shtml
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