CHEMOTHERAPY: HAIR LOSS IS PREVENTABLE

Cancer is a terrible disease. The symptoms of cancer range from headache, nausea, and vomiting, to jaundice, pain, and neuropathy, depending on the site of the primary tumor. The treatment for cancer—chemotherapy—is terrible, too. Chemotherapy is the administration of highly potent, cytotoxic drugs that target cancer cells and select them for cellular death. To expand on this, the key words here are:

     Highly potent drugs:  chemotherapeutic agents are essentially poisons designed to

           selectively kill the rapidly multiplying cancer cells.

     Target cancer cells: chemotherapeutic agents do selectively kill cancer cells, but they also

           have harmful effects on normal cells, particularly hair follicles, bone marrow, and the

           digestive tract.

It’s chemotherapy’s effects on normal cells that get the attention of this blog post.

Chemotherapeutic drugs cause fatigue, weakness, nausea, vomiting, loss of appetite, mouth sores, hormonal changes, neuropathy, low white blood cell count, anemia and hair loss, among other things. All of these are bothersome and annoying symptoms that make life miserable for patients on chemo. They feel bad all the time. But the adverse effect chemo patients are more concerned about than any other is chemotherapy-induced alopecia, CIA, or hair loss. Hair loss is what everyone else sees. It’s obvious immediately and coupled with weight loss, a thin, gaunt appearance, other folks can tell there’s something wrong with you that is serious. Hair loss occurs with most chemo drugs. Some drugs are worse than others, of course, as is the case with most things. 

Chemotherapy-induced alopecia, or CIA, has received a lot of attention because of the profound social and emotional effect it has had on men and women who experience it during cancer treatment. The overall incidence of CIA is 65% in cancer patients and survivors. 88% of female cancer patients say it’s the “most disturbing condition” of chemotherapy. It is information like this that has served to motivate investigators to find treatments that will prevent it. One of the most effective treatments for CIA is cooling of the scalp during infusion of chemotherapeutic drugs. It is FDA-approved, safe, and effective, especially in patients who receive anthracycline-based chemo agents. 

“The success of scalp cooling may vary according to chemotherapeutic drug, dose, and combination,” as well as the cooling cap used, the scalp temperature achieved, and the length of time the scalp is cooled. 

Hair loss from chemo appears within days or weeks of the start of chemotherapy. Chemo drugs interrupt the cellular division (multiplication) of the hair follicle and destroy the hair shaft. The hair fibers then fall out. This occurs all over the body, but most often and most notably on the scalp. After cessation of chemo, hair regrowth begins within 1-3 months, but can take up to 6 months for complete regrowth.

Scalp cooling has been around since the 1970’s, but I have never seen it used before. Several companies make cooling systems—Dignicap Scalp Cooling System, Amma by Cooler Heads, and Paxman Cooling System to name a few. These systems constrict small blood vessels in the scalp and slow down cell growth and cell division in the hair follicles. The cooling cap is applied and started 30 minutes before the infusion begins. It remains in place throughout the infusion, and for 90 minutes after. “The duration of scalp cooling appears to be the influential factor in hair preservation. Cooling is started 30 minutes early so the scalp temperature is at its lowest level when the drug enters the follicles.” The scalp cap “should be changed every 25 minutes during the infusion to ensure a stable temperature….maintaining stable low scalp skin temperatures is crucial.”

In one study of breast cancer patients treated with a specific chemotherapy regimen, scalp cooling failed 48%-67% of the time. So instead of cooling for 90 minutes post infusion they lengthened the time to 150 minutes and saw very little improvement. This showed two things: cooling for 90 minutes was long enough, and the effect of some drug combinations is resistant to scalp cooling. This reiterates the fact that scalp cooling is effective only for certain chemo drug classes. That class is anthracycline-based drugs. For non anthracycline-based drugs cooling is ineffective. 

Scalp cooling is not recommended for leukemia, lymphoma, multiple myeloma, head and neck cancers, or nervous system malignancies. The references say scalp cooling has been around since the 1970’s, but I have never heard of until recently. Maybe some oncologists aren’t convinced it works or find the use of it too much trouble. There’s also a possibility it’s not covered by Medicare or private insurance. According to a reference, “availability and insurance coverage vary, though Medicare and some private insurers have expanded coverage for mechanical cooling systems.” 

References: https://link.springer.com/article/10.1007/s00520-003-0451-y

Mois F, van den Hurt,  Vingerhoets CJ, Breed WPM. Scalp cooling to prevent chemotherapy 

-induced hair loss: practical and Clinical considerations. Support care Cancer 2009 Feb;17(2):181-9.

Komen MMC, Vanden Hurk CJG, Nortier JWR, et al. Prolonging the duration of post-infusion scalp cooling in the prevention of anthracycline-induced alopecia: a randomized trial in patients with breast cancer treated with adjuvant chemotherapy. Support Care Cancer 2019 May;27(5):1919-1925.

Ron IG, Kalmus Y, Kalmus Z, Inbar M, Chaitchix T. Scalp cooling in the prevention of alopecia in patients receiving depilating chemotherapy. Support Cancer Care 1997 Mar;5(2):136-138.

Smetanay K, et al. COOLHAIR: a prospective randomized trial to investigate the efficacy and tolerability of scalp cooling in patients undergoing (neo)adjuvant chemotherapy for

 early breast cancer. Breast Cancer Res Treat 2019 Jan;173(1):135-143.

Amarillo D, de Boni D, Cuello M. Chemotherapy, Alopecia, and Scalp Cooling. Act as Dermosiflior 202 Mar;113(3):278-283.

Tollenaar RAEM, Liefers GJ, Repelaer Van Driel OJ, Van De Velde CJH. SS

Scalp cooling has no place in the prevention of alopecia in adjuvant chemotherapy for breast cancer. Eur J Cancer 1994;30 A(19):1448-1453.

Rudderheim M, et al. Scalp hypothermia to prevent chemotherapy-induced alopecia is effective and safe: a digitized scalp-cooling system used in 74 patients. Support Care Cancer 2003 June;11(6):371-377.