Scalp Cooling to Prevent Chemotherapy-Induced Hair Loss

Summary and Conclusions

Technology and target group

Hair loss, a side effect of some types of chemotherapy, is a very negative experience for some patients. Scalp hypothermia (scalp cooling) is one approach used to prevent hair loss. The most common types of scalp hypothermia involve the use of either a pre-cooled cap or a cooling system that continuously cools a cap. Cooling must be started approximately 30 minutes prior to chemotherapy and must continue for 30 to 90 minutes after the conclusion of treatment. The target group for scalp hypothermia is estimated to be at least 2000 patients per year, ie, patients with metastatic cancer who receive the types of chemotherapy associated with a high risk for hair loss.

Primary question

This assessment is based on a systematic literature review. Does scalp hypothermia prevent, or reduce the extent of, hair loss from chemotherapy?

Patient benefit

Several studies, most of which included a very small number of patients, found that scalp hypothermia helped prevent chemotherapy-induced hair loss. Several different types of chemotherapy, in various combinations, were studied. Different degrees of hypothermia were used, and different assessment criteria were applied. The percentage of patients in the study group who were able to keep their hair ranged from 10 percent to 100 percent, while the corresponding figures in the control group ranged between 0 percent and 19 percent. Apprehension about increased risk for scalp metastases has restricted the use of the method. This risk appears to be small, but the evidence is limited. Theoretically, the method could create a reservoir in the cooled scalp where circulating cancer cells might avoid the effects of chemotherapy. The magnitude of this risk is unknown since patients in the studies have not been followed up for a sufficient period to make this determination. Although the method causes some discomfort to the patient, most patients accept this in order to avoid hair loss.

Economic aspects

The costs for scalp hypothermia are comprised of equipment costs, particularly devices for continuous hypothermia, and costs related to additional working hours and longer treatment sessions. No studies were identified that addressed the cost effectiveness of the method.

SBU´s appraisal of the evidence

There is moderately strong scientific evidence that scalp hypothermia reduces the extent of hair loss when treating solid tumors with various non-taxane chemotherapies alone or in combination (Evidence Grade 2)*. There is limited scientific evidence showing that the method also reduces the extent of hair loss in taxane or taxane-based combination chemotherapy (Evidence Grade 3)*. There is no scientific documentation on the cost effectiveness of the method. Further studies of patient benefit, risks, and cost effectiveness are needed.

*Grading of the level of scientific evidence for conclusions. The grading scale includes four levels;
Evidence grade 1 = strong scientific evidence,
Evidence grade 2 = moderately strong scientific evidence,
Evidence grade 3 = limited scientific evidence,
Evidence grade 4 = insufficient scientific evidence.

This summary is based on a report prepared at SBU in collaboration with Birgitta Ekström (expert), RN, Linköping University Hospital, Per Rosenberg (expert), MD, PhD, Linköping University Hospital, Assoc. Prof. Anita Gustavsson (reviewer), Lund University Hospital, and Birgitta Johansson (reviewer), RN, PhD, Uppsala University.

The complete report is available only in Swedish.

SBU Alert is a service provided by SBU in collaboration with the Medical Products Agency, the National Board of Health and Welfare, and the Swedish Association of Local Authorities and Regions.

References

1. Dorr VJ. A practitioners guide to cancer-related alopecia. Semin Oncol 1998;25(5):562-70. Review.
2. Noble-Adams R. Scalp cooling: a critical examination. Nurs Prax N Z 1998;13(3):35-44. Review.
3. Cline BW. Prevention of chemotherapy-induced alopecia: a review of the literature. Cancer Nurs 1984;7(3):221-8. Review.
4. Gunnars B. Livskvalitet under cytostatikabehandling: en studie av cancerpatienters upplevelser och erfarenheter. Lund, Sverige; 1991.
5. SBU report no 155/2. Chemotherapy for cancer: SBU - the Swedish Council on Technology Assessment in Health Care, Stockholm; 2001.
6. Gregory RP, Cooke T, Middleton J, Buchanan RB, Williams CJ. Prevention of doxorubicin-induced alopecia by scalp hypothermia: relation to degree of cooling. Br Med J (Clin Res Ed) 1982;284(6330):1674.
7. Belpomme D, Mignot L, Grandjean M, Pujade-Lauraine E, Le Rol A, Gisselbrecht C et al. [Prevention of chemotherapy-induced alopecia in cancer patients by scalp hypothermia] Nouv Presse Med 1982;11(12):929-31.
8. Ridderheim M, Bjurberg M, Gustavsson A. Scalp hypothermia to prevent chemotherapy-induced alopecia is effective and safe: a pilot study of a new digitized scalp-cooling system used in 74 patients. Support Care Cancer 2003;11(6):371-7.
9. Lemenager M, Lecomte S, Bonneterre ME, Bessa E, Dauba J, Bonneterre J. Effectiveness of cold cap in the prevention of docetaxel-induced alopecia. Eur J Cancer 1997;33(2):297-300.
10. Edelstyn GA, MacDonald M, MacRae KD. Doxorubicin-induced hair loss and possible modification by scalp cooling. Lancet 1977;2(8031):253-4.
11. Satterwhite B, Zimm S. The use of scalp hypothermia in the prevention of doxorubicin-induced hair loss. Cancer 1984;54(1):34-7.
12. Kennedy M, Packard R, Grant M, Padilla G, Presant C, Chillar R. The effects of using Chemocap on occurrence of chemotherapy-induced alopecia. Oncol Nurs Forum 1983;10(1):19-24.
13. Parker R. The effectiveness of scalp hypothermia in preventing cyclophosphamide-induced alopecia. Oncol Nurs Forum 1987;14(6):49-53.
14. Giaccone G, Di Giulio F, Morandini MP, Calciati A. Scalp hypothermia in the prevention of doxorubicin-induced hair loss. Cancer Nurs 1988;11(3):170-3.
15. Macduff C, Mackenzie T, Hutcheon A, Melville L, Archibald H. The effectiveness of scalp cooling in preventing alopecia for patients receiving epirubicin and docetaxel. Eur J Cancer Care (Engl) 2003;12(2):154-61.
16. Ron IG, Kalmus Y, Kalmus Z, Inbar M, Chaitchik S. Scalp cooling in the prevention of alopecia in patients receiving depilating chemotherapy. Support Care Cancer 1997;5(2):136-8.
17. Luce JK, Raffetto TJ, Crisp M et al. Prevention of alopecia by scalp cooling of patients receiving Adriamycin. Cancer Chemother Rep 1973;57:108-9.
18. Symonds RP, McCormick CV, Maxted KJ. Adriamycin alopecia prevented by cold air scalp cooling. Am J Clin Oncol 1986;9(5):454-7.
19. Robinson MH, Jones AC, Durrant KD. Effectiveness of scalp cooling in reducing alopecia caused by epirubicin treatment of advanced breast cancer. Cancer Treat Rep 1987;71(10):913-4.
20. 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(2):121-30.
21. Anderson JE, Hunt JM, Smith IE. Prevention of doxorubicin-induced alopecia by scalp cooling in patients with advanced breast cancer. Br Med J (Clin Res Ed) 1981;282(6262):423-4.
22. Aloxopoulos CG, Chera P, Pothitos G et al. A new technique of scalp cooling in preventing alopecia induced by anticancer chemotherapy. Eur J Cancer 1999;(suppl 4):378.
23. Wheelock JB, Myers MB, Krebs HB, Goplerud DR. Ineffectiveness of scalp hypothermia in the prevention of alopecia in patients treated with doxorubicin and cisplatin combinations. Cancer Treat Rep 1984;68(11):1387-8.
24. Tollenaar RA, Liefers GJ, Repelaer van Driel OJ, van de Velde CJ. Scalp cooling has no place in the prevention of alopecia in adjuvant chemotherapy for breast cancer. Eur J Cancer 1994;30A(10):1448-53. Review.
25. Protiere C, Evans K, Camerlo J, dIngrado MP, Macquart-Moulin G, Viens P et al. Efficacy and tolerance of a scalp-cooling system for prevention of hair loss and the experience of breast cancer patients treated by adjuvant chemotherapy. Support Care Cancer 2002;10(7):529-37.
26. Christodoulou C, Klouvas G, Efstathiou E, Zervakis D, Papazachariou E, Plyta M et al. Effectiveness of the MSC cold cap system in the prevention of chemotherapy-induced alopecia. Oncology 2002;62(2):97-102.
27. Semsek D, Fiebig HH, Klöpfer P et al. Scalp hypothermia for 3 hours reduces alopecia after anthracycline based chemotherapy. Annal Oncol 2000 (suppl 4);11:154.
28. Katsimbri P, Bamias A, Pavlidis N. Prevention of chemotherapy-induced alopecia using an effective scalp cooling system. Eur J Cancer 2000;36(6):766-71.
29. Middleton J, Franks D, Buchanan RB, Hall V, Smallwood J, Williams CJ. Failure of scalp hypothermia to prevent hair loss when cyclophosphamide is added to doxorubicin and vincristine. Cancer Treat Rep 1985;69(4):373-5.
30. David J, Speechley V. Scalp cooling to prevent alopecia. Nurs Times 1987;83(32):36-7.
31. Vendelbo Johansen L. Scalp hypothermia in the prevention of chemotherapy-induced alopecia. Acta Radiol Oncol 1985;24(2):113-6.
32. McGarvey EL, Baum LD, Pinkerton RC, Rogers LM. Psychological sequelae and alopecia among women with cancer. Cancer Pract 2001;9(6):283-9. Review.
33. Batchelor D. Hair and cancer chemotherapy: consequences and nursing care--a literature study. Eur J Cancer Care (Engl) 2001;10(3):147-63. Review.
34. Breed WP. What is wrong with the 30-year-old practice of scalp cooling for the prevention of chemotherapy-induced hair loss? Support Care Cancer 2004;12(1):3-5.