Patients receiving anticancer treatment need help to prevent and alleviate adverse events while coping with the disease itself. Treatment may affect skin, nails, and hair, all integral components of overall health, appearance, and, as a result, a sense of self.

Chemotherapy-induced alopecia, which usually starts 1–3 weeks after initiating anticancer therapy and is one of the most reported unpredictable adverse events experienced by cancer patients and survivors, generally results in diffuse grade 2 alopecia on the entire scalp.  In addition, patients might also experience diffuse partial alopecia or patchy, unevenly distributed alopecia. In some cases, it involves the eyebrows, eyelashes (madarosis), and body hair. With an overall, reported incidence of 65%, chemotherapy-induced alopecia has been reported as the most disturbing condition of cancer treatment by the majority of women (88%) receiving perioperative chemotherapy. As a result of the potential of chemotherapy-induced alopecia, some patients may decline life-prolonging chemotherapy to avoid alopecia.[1][2]

Preventing chemotherapy-induced alopecia
Because of the severity of the impact of chemotherapy-induced alopecia in cancer patients, researchers have investigated how certain medications or procedures could potentially reduce or prevent alopecia.

While some topicals, such as minoxidil (Loniten®; Pfizer), an antihypertensive vasodilator used for the treatment of high blood pressure and male-pattern hair loss, or bimatoprost (Lumigan®; Allergan) a prostaglandin used to treat high pressure inside the eye including glaucoma and was recently thought to be linked to hair growth, have shown to be effective in stimulation of hair regrowth after chemotherapy, they don’t preventive chemotherapy-induced alopecia.

In contrast, scalp cooling has been frequently been described as safe, effective, and generally well tolerated. [3]

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Since the 1970s a variety of different scalp cooling approaches have been used to help minimize the potential adverse effects of chemotherapy-induced alopecia, including cryogel bags, cold caps such as Elasto-gel and Penguin, and cooling machines such as Paxman, Dignitana. [4][5]

Scalp cooling causes vasoconstriction in the scalp skin, reducing decreased intrafollicular metabolic rate, and decreased follicular uptake of chemotherapeutic drugs like doxorubicin. In theory, this reduces follicular exposure to harmful cytotoxic effects at their peak plasma concentrations. In other words, by lowering scalp temperature before, during, and after the administration of chemotherapy, scalp cooling may alleviate the damage caused to the hair follicle, thus helping patients to retain their hair during treatment.

The success of this approach varies according to the chemotherapeutic agent, drug combination, and dose and, in addition, depends on the scalp temperature,  duration of therapy, and proper fitting of the cooling cap.[6]

Clinical practice guideline
Based on the available evidence, the European Society for Medical Oncology (ESMO) has updated the Clinical Practice Guidelines for Dermatological Toxicities Related to Anticancer Agents to include the recommendation of scalp cooling for the prevention of chemotherapy-induced alopecia (CIA) as a Category IIB recommendation.[7]

A multidisciplinary group of experts from institutions and countries across Europe, the United States, and Australia authored the updated guidelines.

The adoption of this recommendation by ESMO follows the US National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in oncology for breast cancer (Version 1.2019) update in 2019 to include scalp cooling as a Category 2A recommendation, and subsequently the Clinical Practice Guidelines in oncology for Ovarian Cancer, Fallopian Tube Cancer and Primary Peritoneal Cancer (Version 1.2020) along with the updated ‘Guidance for the management of early breast cancer’ by Cancer Australia earlier this year.

The British scalp cooling expert Paxman – whose pioneering cold cap system has helped over 100,000 cancer patients worldwide to retain their hair during chemotherapy – welcomed the recommendation and its wider potential for positive change.

“Clinical Practice Guidelines effectively determine standards of care around the world and this adoption by ESMO will work towards a positive change in the supportive cancer care landscape. Paxman is the scalp cooling provider for many leading cancer centers throughout Europe and this update will serve to the continuation of our international mission in eliminating hair loss from chemotherapy and thus change the face of cancer,”  noted Richard Paxman, Chief Executive Officer of Paxman.

Paxman explained that his Scalp Cooling System provides a clinically proven hair loss prevention system for cancer patients undergoing chemotherapy. The system is used at a large number of cancer centers and hospitals in Europe, North-, Central- and South America, Asia, and Oceania, and is responsible for helping patients keep their hair and retain normality during cancer treatment.

Of the various interventions proposed for the prevention of chemotherapy-induced alopecia, scalp cooling has emerged as the most effective. [1]. However, clinicians are advised that in the case of limited prophylactic or therapeutic options to prevent, or treat, alopecia, it is essential to inform patients about this adverse event before commencing therapy and to speak about aids.

The Guidelines also note that scalp cooling may be less effective with anthracycline-containing regimens.

Highlights of prescribing information
Minoxidil (Loniten®; Pfizer)[Prescribing Information]
Nimatoprost (Lumigan®; Allergan) [Prescribing Information]

[1] Silva GB, Ciccolini K, Donati A, Hurk CVD. Scalp cooling to prevent chemotherapy-induced alopecia. An Bras Dermatol. 2020 Sep-Oct;95(5):631-637. doi: 10.1016/j.abd.2020.03.005. Epub 2020 Jun 16. PMID: 32622629; PMCID: PMC7563013.
[2] Protière C, Evans K, Camerlo J, d’Ingrado MP, Macquart-Moulin G, Viens P, Maraninchi D, Genre D. 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 Oct;10(7):529-37. doi: 10.1007/s00520-002-0375-y. Epub 2002 Aug 15. PMID: 12324807.
[3] 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 Jun;11(6):371-7. doi: 10.1007/s00520-003-0451-y. Epub 2003 Mar 21. PMID: 12768403.
[4] Dean JC, Griffith KS, Cetas TC, Mackel CL, Jones SE, Salmon SE. Scalp hypothermia: a comparison of ice packs and the Kold Kap in the prevention of doxorubicin-induced alopecia. J Clin Oncol. 1983 Jan;1(1):33-7. doi: 10.1200/JCO.1983.1.1.33. PMID: 6668482.
[5] Peck HJ, Mitchell H, Stewart AL. Evaluating the efficacy of scalp cooling using the Penguin cold cap system to reduce alopecia in patients undergoing chemotherapy for breast cancer. Eur J Oncol Nurs. 2000 Dec;4(4):246-8. doi: 10.1054/ejon.2000.0094. PMID: 12849021.
[6] Van den Hurk CJ, Peerbooms M, van de Poll-Franse LV, Nortier JW, Coebergh JW, Breed WP. Scalp cooling for hair preservation and associated characteristics in 1411 chemotherapy patients – results of the Dutch Scalp Cooling Registry. Acta Oncol. 2012 Apr;51(4):497-504. doi: 10.3109/0284186X.2012.658966. Epub 2012 Feb 6. PMID: 22304489.
[7] Lacouture ME, Sibaud V, Gerber PA, van den Hurk C, Fernández-Peñas P, Santini D, Jahn F, Jordan K; ESMO Guidelines Committee. Prevention and Management of Dermatological Toxicities Related to Anticancer Agents: ESMO Clinical Practice Guidelines. Ann Oncol. 2020 Nov 25:S0923-7534(20)43157-6. doi: 10.1016/j.annonc.2020.11.005. Epub ahead of print. PMID: 33248228.

Featured image: Patient scalp cooling with Paxman System. Photo courtesy: © 2020 Paxman System. Used with permission.

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