By Charbel C. Khoury, MD
August 8, 2015
Being diagnosed with cancer can be devastating and life-changing. Furthermore, the side effects of chemotherapy are often very distressing, and hair loss is one of the more feared complications. When a patient, and particularly a woman, loses her hair to chemotherapy, she is faced with the stigma of the disease, and may feel that she is losing her identity, femininity, and sexuality.1 Patients with chemotherapy-associated alopecia are confronted with the lethal nature of cancer, and a minority of patients even choose to avoid chemotherapy for fear of losing their hair.
Scalp cooling has been previously proposed to prevent hair loss, however up until recently, its efficacy had been debated. The underlying premise is that cooling slows metabolism in hair follicles, and leads to vasoconstriction of scalp blood vessels, thereby reducing blood flow and delivery of toxic chemotherapeutic agents to the follicles.
Recently in JAMA, results from the Scalp Cooling Alopecia Prevention (SCALP) trial were published.2 This was a multicenter, randomized, nonblinded study conducted from 2013 to 2016, that recruited women with stage I or II breast cancer and planning to receive at least four cycles of taxane- and/or anthracycline-based chemotherapy for curative intent. One hundred and eighty-two participants were randomized in a 2:1 ratio to scalp cooling using a scalp cooling device vs control. However, the interim analysis showed the superiority of scalp cooling, and the study was terminated early, when 95 patients in the cooling group and 47 patients in the control group had completed four cycles of chemotherapy. Results were analyzed in a modified intent-to-treat analysis.
Hair preservation, defined as no hair loss or loss of <50% of hair not requiring a wig, was found in 48 of 95 women with cooling (50.5%; 95%CI, 40.7%-60.4%) compared with 0 of 47 women in the control group (0%; 95%CI, 0%-7.6%). Overall, patients felt reasonably comfortable, only 6 patients withdrew from the scalp cooling arm of the trial. Complications included chills, dizziness, headache, nausea, paresthesia, pruritus, sinus pain, skin and subcutaneous tissue disorders, and skin ulceration, all were mild to moderate. However, detection of complications is affected by the early termination of the trial. Follow-up was not long enough to rule out scalp metastases, however other observational studies suggest that the risk would be very low.3
This study had some important limitations. Stopping the trial early affects the power to detect differences, and patients who continued chemotherapy for longer than four cycles could have lower rates of hair retention at a later time point. No differences in quality of life were seen between patients in the cooling group (with or without hair preservation), and those in the non-cooling group. Furthermore, there were notable differences in success rates between study sites (attributed to a learning curve in using the cooling device) and between treatment regimens (16% success in anthracycline-treated patients versus 59% in taxane-treated). Currently, scalp cooling can cost about $1500 to $3000 total per patient and is not reimbursed by health insurance. Further data on benefits are likely to be needed to overcome this.
Despite the limitations of this study, the results are encouraging and suggest that scalp cooling devices are a safe and feasible intervention which could limit or even prevent this common and highly distressing treatment-related complication affecting many women with cancer.
- Rosman, S. 2004. Cancer and stigma: experience of patients with chemotherapy-induced alopecia, Patient Educ Couns, 52: 333-9.
- Nangia, J., T. Wang, C. Osborne, P. Niravath, K. Otte, S. Papish, F. Holmes, J. Abraham, M. Lacouture, J. Courtright, R. Paxman, M. Rude, S. Hilsenbeck, C. K. Osborne, and M. Rimawi. 2017. Effect of a Scalp Cooling Device on Alopecia in Women Undergoing Chemotherapy for Breast Cancer: The SCALP Randomized Clinical Trial, JAMA, 317: 596-605.
- Lemieux, J., C. Amireault, L. Provencher, and E. Maunsell. 2009. Incidence of scalp metastases in breast cancer: a retrospective cohort study in women who were offered scalp cooling, Breast Cancer Res Treat, 118: 547-52.
Dr. Charbel C. Khoury is a renal fellow at the Brigham and Women’s and Massachusetts General Hospitals in Boston. He is also a Clinical Nutrition Fellow at the Brigham and Women’s Hospital.