Chemotherapy-induced alopecia (CIA) is one of the most visible adverse side effects of cancer treatment. The trauma of CIA has been well documented in the psychological literature.1-4 Among side effects, alopecia is considered one of the most distressing experiences for women with breast cancer.3 For some women, losing hair has been described as a more difficult experience than losing breasts.1,3 Women with alopecia may experience a loss of femininity, sexuality, and self-confidence, and hair loss has been associated with lower body image, loss of sense of self, and depression.2,3 Moreover, patients relayed social avoidance due to concerns of their appearance.2,3
To reduce the incidence of CIA, scalp cooling methods emerged in the 1970s as an intervention to promote hair preservation. Primarily investigated in Europe, early techniques were found to be a promising modality for the prevention of CIA.5 The use of scalp cooling in the United States lagged due to insufficient prospective efficacy data, lack of FDA clearance, and safety concerns about potential increase in scalp metastasis due to diminished chemotherapy delivery.6 Recent studies have shown no association between scalp cooling and scalp metastases or decreased survival among patients with breast cancer.7-9
Although the methodology has evolved, the principle remains the same. Scalp cooling works by causing cutaneous vasoconstriction, reducing the follicular metabolic rate, which impedes the delivery of cytotoxic agents to hair follicles and results in diminished uptake.7,8 Many academic hospital and stand-alone oncology practices now discuss scalp cooling options as part of chemotherapy education for breast cancer patients. Scalp cooling is accomplished through portable systems or center-based machines. There are challenges and advantages with each type.
Portable systems include multiple caps kept cold on dry ice that is secured by and brought to the cancer center by the patient in a large cooler. These caps (usually 6-8) are changed throughout the chemotherapy infusion and must be worn before and after treatment for several hours. The patient must bring an assistant to help with the frequent cap changes. Penguin Cold Caps and Arctic Cold Caps are well-known providers of the portable systems.
Cancer center–based machines utilize a specially formulated coolant that circulates from a small refrigeration machine through a closed cap on the patient’s head. The patient brings her own personally fitted cap to and from chemotherapy treatments. The patient must stay connected to the machine during the scalp cooling process. Paxman and DigniCap are well-known providers of the center-based systems.
Breast cancer patients are increasingly interested in scalp cooling to decrease the risk of CIA. Scalp cooling systems have proved effective in reducing rates of alopecia according to randomized clinical trials, but with some variability.7,10-14 Studies have shown that different chemotherapy regimens have different rates of hair preservation success. Higher rates of hair preservation are generally seen with taxane-based versus anthracycline-based chemotherapies. Documented success rates range from as low as 16% to 22% with anthracycline-based regimens compared with 45% to 80% with taxane-based regimens.7,11-13 Another study found that drug sequence can also impact success. Scalp cooling was more effective when patients were started on taxanes first followed by anthracyclines compared with the reverse sequence.7
Success rates are also influenced by a number of other variables. Ethnicity, age, hair thickness, scalp cooling device, cap fitting techniques, and patient compliance all impact the success of alopecia prevention.11-13 Scalp cooling will not prevent hair loss in all women, and success may be partial instead of complete. Studies assessing the effect of scalp cooling on well-being have shown that scalp-cooled patients with alopecia had significantly worse quality-of-life outcomes than non–scalp-cooled patients with alopecia.15,16 Whereas many aspects of cancer treatment, such as side effects and surgery, can negatively impact well-being, the disappointment of unsuccessful hair preservation may also be a contributing factor.
The cost associated with scalp cooling can be substantial, especially when a center-based system is used. Unfortunately, scalp cooling at this time is rarely covered by health insurance plans. Makers of scalp cooling devices provide some financial assistance, and there are independent nonprofits that also work to alleviate the financial burden. However, many financial support options are through reimbursement. This is a challenge for many women who do not have the resources to pay up front.
Role of Patient Navigators
Perhaps most valuably, patient navigators can guide women in self-reflection on the importance of hair loss to their emotional adjustment and recovery. Some women look to hide alopecia to avoid being identified as a cancer patient. Others might want to hide hair loss as a way to protect family members, such as children or grandchildren, from stress and worry. Yet for some, taking control of CIA involves the empowering act of head shaving, maybe donation of hair to organizations that create wigs for children, and embracing baldness.17 Open communication about cancer treatment and its side effects is vital to understanding patient needs and providing individualized resources to support them throughout treatment.
Patient navigators can help facilitate successful individual use of scalp cooling. At a time when a newly diagnosed woman is feeling overwhelmed, navigators can prioritize needed information to what she must know to make the time-sensitive decision about scalp cooling. Educational materials should come directly from the manufacturers of the scalp cooling devices; however, navigators can tailor materials to the learning styles and lived cultural experience of specific patients.18,19 Navigators can assess for learning differences, low literacy, or English as a second language and direct women to handouts, informational videos, and simple charts to detail the number of expected treatments, time frame, costs associated with each treatment, and side effects to promote informed decision-making.
Navigators can also help women identify how realistically scalp cooling can be accomplished. Supportive care requires balancing emotional and practical needs. Some pragmatic questions to consider with scalp cooling include: How effective is scalp cooling with the chemo I will receive? Do I have a support person who can help me put on or change caps? Does the cost of scalp cooling fit into my budget? Answers to these questions can help women understand the potential benefits, limitations, alternatives, and uncertainties to foster realistic expectations.
Finally, patient navigators can assist patients with addressing barriers to cost. Navigators can brainstorm with patients on ways to accomplish their goals while avoiding financial toxicity. Women might consider asking for donations from family and friends, or seeking grants from community and national organizations. Connecting patients with a social worker can be helpful. A social worker might identify financial resources for cancer treatment or recognize hidden expenses not anticipated, which can throw off budgeting goals.
Scalp cooling is an effective tool to reduce the incidence of CIA. Identifying appropriate candidates requires consideration of multiple factors, including chemotherapy drugs, treatment length, ethnicity, and hair volume and quality. The psychological and social impact of hair loss perceived by the patient must also be balanced with efficacy and costs of the intervention. Navigators are fundamental in optimizing this experience for breast cancer patients by providing education, resources, and support.
- Lemieux J, Maunsell E, Provencher L. Chemotherapy-induced alopecia and effects on quality of life among women with breast cancer: a literature review. Psychooncology. 2008;17:317-328.
- Dua P, Heiland MF, Kracen AC, Deshields TL. Cancer-related hair loss: a selective review of the alopecia research literature. Psychooncology. 2017; 26:438-443.
- Choi EK, Kim IR, Chang O, et al. Impact of chemotherapy-induced alopecia distress on body image, psychosocial well-being, and depression in breast cancer patients. Psychooncology. 2014;23:1103-1110.
- Trusson D, Pilnick A. The role of hair loss in cancer identity: perceptions of chemotherapy-induced alopecia among women treated for early-stage breast cancer or ductal carcinoma in situ. Cancer Nurs. 2017;40:E9-E16.
- Dean JC, Salmon SE, Griffith KS. Prevention of doxorubicin-induced hair loss with scalp hypothermia. N Engl J Med. 1979;301:1427-1429.
- Rugo HS, Klein P, Melin SA, et al. Association between use of a scalp cooling device and alopecia after chemotherapy for breast cancer. JAMA. 2017;317:606-614.
- Baipai J, Kagwade S, Chandrasekharan A, et al. Randomised controlled trial of scalp cooling for the prevention of chemotherapy induced alopecia. Breast. 2020;49:187-193.
- Massey CS. A multicentre study to determine the efficacy and patient acceptability of the Paxman Scalp Cooler to prevent hair loss in patients receiving chemotherapy. Eur J Oncol Nurs. 2004;8:121-130.
- Lemieux J, Provencher L, Perron L, et al. No effect of scalp cooling on survival among women with breast cancer. Breast Cancer Res Treat. 2015; 149:263-268.
- Rugo HS, Voigt J. Scalp hypothermia for preventing alopecia during chemotherapy: a systematic review and meta-analysis of randomized controlled trials. Clin Breast Cancer. 2018;18:19-28.
- Cigler T, Isseroff D, Fiederlein B, et al. Efficacy of scalp cooling in preventing chemotherapy-induced alopecia in breast cancer patients receiving adjuvant docetaxel and cyclophosphamide chemotherapy. Clin Breast Cancer. 2015;15:332-334.
- Nangia J, Wang T, Osborne C, et al. Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer. The SCALP Randomized Clinical Trial. JAMA. 2017;317:569-605.
- Chan A, Bauwens A, Pontre S, et al. Efficacy of scalp cooling in reducing alopecia in early breast cancer patients receiving contemporary chemotherapy regimens. Breast. 2018;41:127-132.
- Kinoshita T, Nakayama T, Fukuma E, et al. Efficacy of scalp cooling in preventing and recovering from chemotherapy-induced alopecia in breast cancer patients: the HOPE Study. Front Oncol. 2019;9:733.
- Van den Hurk CJG, Mols F, Vingerhoets AJJM, Breed WPM. Impact of alopecia and scalp cooling on the well-being of breast cancer patients. Psychooncology. 2010;19:701-709.
- Marks DH, Okhovat JP, Hagigeorges D, et al. The effect of scalp cooling on CIA-related quality of life in breast cancer patients: a systematic review. Breast Cancer Res Treat. 2019;175:267-276.
- Torres E, Dixon C, Richman AR. Understanding the breast cancer experience of survivors: a qualitative study of African American women in rural eastern North Carolina. J Cancer Educ. 2016;31:198-206.
- Samuel CA, Schaal J, Robertson L, et al. Racial differences in symptom management experiences during breast cancer treatment. Support Care Cancer. 2018;26:1425-1435.
- Teteh DK, Montgomery S, Monice SB, et al. My crown and glory: community, identity, culture, and black women’s concerns of hair product-related breast cancer risk. Cogent Arts & Humanities. 2017;4:1-17.