By Fran Boyle, University of Sydney.
Chemotherapy induced alopecia (CIA) remains a major unmet need in cancer supportive care.
It has a significant impact on patient quality of life, body image, social interactions and immediately identifies to the world that the patient has cancer. It may even influence patients to decline potentially life saving treatment.
The only proven strategy to reduce CIA is scalp cooling. Reducing the scalp temperature below 22° C reduces blood flow to the scalp, but more importantly slows hair follicle cycling. Cooling commences prior to chemotherapy and is continued during the infusion and for a variable time post infusion (typically 1-2 hours) to cover the peak serum levels. Widely used in the UK and Europe for a decade, it is beneficial in patients with breast, prostate, colorectal, lung and gynaecological cancers receiving chemotherapy with a variety of regimens. No increase in scalp metastases has been observed in large cohort studies.
“Do you know what? It gives you one little layer of control. I was assuming I was going to lose it, and then it was like a life raft…” Patient comment
Scalp cooling has been infrequently used in Australia, and experience with older frozen cap systems was disappointing, and caused significant patient discomfort and nursing staff workload. Over the past 2 years however, 2 new European devices have been TGA approved and marketed in Australia, made by Dignitana and Paxman. These utilise a chair-side refrigeration unit which circulates coolant through a cap that does not require changing. Patient comfort is improved and less nursing time is required.
At the Mater in Sydney we have implemented scalp cooling over the past 3 years using all of the available devices, led by the Nursing Unit Manager of the Patricia Ritchie Centre, Kerrie Andrews and funded by the Friends of the Mater Foundation. Penguin cold caps, Dignitana and Paxman devices all produce similar results in women with early breast cancer receiving adjuvant therapy with TC (60% lose less than 50%), FEC-D (40% lose less than 50%) and other Herceptin containing regimens. We have also utilised the coolant systems in patient with metastatic breast and prostate cancer receiving Docetaxel with excellent results. Cooling for Eribulin has recently commenced.
Nursing staff have a clear preference for the coolant systems and completion rates are also higher with these due to greater comfort. Focus groups with patients highlight the importance of preserving an appearance of normality for their children and at work, the benefit of being able to take control of at least one thing at a chaotic time, and the need for additional advice on hair care during chemotherapy when hair is changing.
“I was able to hide my breast cancer diagnosis from my work colleagues and children.” Patient comment
Implementation of this new technique has begun at other sites in Australia. Key facilitators appear to be a local nursing champion to drive the change, buy in from the institution and donors, the possibility of altering work flows to accommodate longer chair times, and commencing with small defined patient groups to gain experience, before offering cooling to “all comers”. At the Mater we are happy to assist new sites develop their programs, and are developing a data set for benchmarking, an implementation checklist, and patient education materials which can be shared. Our international collaborations are focused on the development of better patient reported outcome measures, in order to facilitate further trial activity with new agents and device modifications.
It has been both a team challenge and achievement to offer this service to our patients, who report high levels of satisfaction with the opportunity to reduce the impact of chemotherapy on their lives.
Next frontier – eyelashes and eyebrows!
Professor Fran Boyle AM is Professor of Medical Oncology at the University of Sydney and Director of Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital.
Fran presented a breakfast session at the COSA ASM in Melbourne 2014 on scalp cooling and has kindly made her slides available to our readers here (708kb).