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GUIDELINESADMINISTERING OF SCALP COOLING
TO PATIENTS RECEIVING SPECIFIC
ALOPECIA INDUCING
CHEMOTHERAPY TREATMENT
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CONTENTS
Page
3
Definition
Indications
3
Scientific rationale for scalp cooling
4
Types of Drugs
4
Factors which influence success
5
Patient selection
6
Procedure guidelines
7
References and further reading
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Definition
Scalp cooling is a method of preventing chemotherapy-induced alopecia. It
acts by reducing the temperature of the scalp, causing the blood vessels
supplying the hair follicles to constrict; this decreases the amount of drug that
can pass to the hair follicles, thus reducing the cellular uptake of the drug and
the degree of hair loss.
Alopecia is a common consequence of many chemotherapeutic regimens and
is one of the most devastating effects of cancer chemotherapy (Pickard-Holley
1995; Williams et al. 1999). It has been identified as such a devastating
prospect that some patients may refuse to accept treatment (Williams et al.
1999). Hair loss can also result in changes to the patient’s body image
(Freedman 1994) which may not be improved by the regrowth of hair
(Munstedt et al. 1997).
Indications
The effectiveness of scalp cooling has been demonstrated satisfactorily with
doxorubicin, epirubicin, docetaxel and paclitaxel (Dean et al. 1979; Robinson
1987; Lemanager et al. 1995; Katsimbri 2000).
Patients receiving other cytotoxic drugs which may cause alopecia, such as
vindesine and vincristine, have undergone the procedure, although there are
insufficient data to evaluate its effectiveness with these drugs.
Scalp cooling requires the consultant’s permission as the procedure may
protect micrometastases in the scalp from chemotherapy, especially where
there is the possibility of circulating cancer cells, e.g., in cases of leukaemia
and lymphoma (Witman et al. 1981). In spite of this, scalp cooling has been
used successfully in patients with relapsed lymphoma (Purohit et al. 1992)
Dean et al. (1983), drawing on evidence from 7800 women with breast
cancer, found that only two experienced recurrence of disease on the scalp,
suggesting that the risk of scalp metastases was minimal. They concluded
that scalp cooling should not be contraindicated and could be used routhinely
with a wide variety of solid tumours. Nevertheless, patients with advanced
metastatic disease have been found to develop scalp metastases during scalp
cooling and Middleton et al. (1985) argued strongly against the use of scalp
cooling in this group. Other studies have found no scalp metastases at follow
up (Ron et al. 1997). The potential risk of scalp metastases, albeit remote,
should be addressed and demands discussion by health care professionals
and patients (Peck 2000; Batchelor 2001).
The issues relating to scalp metastases are controversial. This dilemma,
along with the media coverage regarding preventive measures for
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chemotherapy-induced alopecia (Carr 1998; Kendall 2001), have led some
practitioners to question whether scalp cooling should be offered. Patients
have highlighted how they feel about hair loss (Carr 1998) and also the need
to provide more comfortable and effective scalp cooling in all cancer units and
centres (Wilson 1994). In addition, an extensive review of the literature
concluded that scalp cooling was effective and should be offered to all
patients for whom it was appropriate (Crowe et al. 1998; Batchelor 2001).
This was supported by the views of many nurses who felt that the use of scalp
cooling with chemotherapy protocols which are associated with hair loss can
effectively prevent alopecia and result in improved quality of life for patients
(Lemanager et al. 1998). Patients also feel it is worthwhile regardless of how
successful it is (Dougherty 2002).
The Scientific Rationale for Scalp Cooling
The rationale is based on characteristics of hair growth, the effect of cytotoxic
drugs on hair follicles, physiological changes in scalp circulation and
pharmacokinetics (Keller & Blausey 1988). Ninety per cent of all scalp hair is
in an active phase of growth. The growth phase is characterised by significant
mitotic activity, thus rendering the hair bulb, especially sensitive to
chemotherapeutic agents (Parker 1987). Scalp hypothermia produces
changes in the scalp circulation by causing vasoconstriction of superficial
vessels. Decreased blood flow to the scalp reduced the amount of the drug
reaching the hair follicles and thus minimises damage to the scalp hair
(Kennedy et al. 1983; Parker 1987. Its success is also related to the
metabolic effects of cooling, i.e., slowing the metabolic rate (Bulow et al.
1985), and it also appears that the degree of hair loss is temperature
dependent. In order to prevent alopecia the temperature of the scalp must be
reduced to at least 24°C but preferably 22°C (Gregory et al. 1988). Then
when the cap is placed on the head the scalp temperature will drop from 37°C
to 23-24°C within the first 15 minutes (Guy et al. 1982; Tollenaar et al. 1994).
This is why a pre injection scalp cooling time of 20-30 minutes is said to be
required (Anderson et al. 1981; Kennedy et al. 1983; Satterwhite & Zimm
1984; Middleton et al. 1985; Robinson 1987; Giacone et al. 1988).
Scalp cooling has been used in an attempt to reduce hair loss with palliative
whole-brain radiotherapy. However, a pilot study (Shah et al. 2000) found that
all patients still lost their hair and there was evidence that the cold cap
application increased the dose of radiotherapy to the scalp.
Types of Drugs
Doxorubin is commonly used in cancer chemotherapy and has a uniquely
short half life of approximately 30 minutes (compared to other drugs, such as
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cyclophosphamide which has a plasma half-life of over 6 hours) (Priestman
1989). This factor makes prophylactic scalp cooling feasible because it need
only be utilised during peak plasma levels (Cline 1984). This is particularly
important since doxorubicin results in a consistently high incidence of alopecia
(80-90% of all patients), often leading to total hair loss (Dean et al. 1983).
The involvement of doxorubicin, whether used alone or in combination, is a
feature of most of the reported scalp cooling studies. In some studies, there
was less success in maintaining hair with increasing doses of doxorubicin
and/or liver metastases (Dean et al. 1983; David & Speechley 1987), but this
may be resolved by extending the time the cap remains in place following
chemotherapy administration.
Scalp cooling has also been used during the administration of epirubicin, as a
single agent, with good results (Robinson 1987), although doses may
influence outcomes (Adam et al. 1992). Subsequent studies have
investigated combination regimens containing epirubicin and other drugs such
as cyclophosphamide is added to any single agent anthracycline, the success
rate is reduced from 80% of patients keeping most of their hair to about 5060% of patients.
Factors Which Influence Success
The success of all these methods in preventing hair loss varies and the
amount of hair loss experienced by the patient is dependent on a number of
factors.:


Involvement of the liver with metastatic disease leads to elevated
plasma levels of doxorubicin for a longer period. Extension of the
cooling period does not seem to improve the results (Satterwhite and
Zimm 1984).
Inadequate cooling because of exceptionally thick hair may lead to
partial loss. It has been demonstrated that maximum cooling occurs 30
minutes after the cap has been placed in position. The weight of the
cap (as well as the temperature) may be a factor, as this ensures that
the contact is maintained over the complete scalp (Hunt et al. 1982).
Success does not appear to be dose dependent as was first thought
(David & Speechley 1987; Dougherty 2002).
It seems likely that when anthracyclines are used in combination with
other drugs that cause alopecia (e.g., etoposide and
clyclophosphamide) the success rate is not as high as with
anthracyclines alone (Middleton et al 1985).
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Patient Selection
All patients with solid tumours receiving doxorubicin, epirubicin docetaxel or
paclitaxel as a single agent or in combination should be offered scalp cooling.
However, scalp cooling should not be offered to:



Patients with haematological disease unless the consultant feels it is
appropriate to offer scalp cooling on the basis of quality of life.
Patients receiving drugs that cause hair loss, e.g., vincristine, where
there is no research or evidence of the effectiveness of scalp cooling.
Patients who have already received a first course of chemotherapy
which may induce hair loss but who were not offered or declined scalp
cooling.
Patients must give verbal or written consent (dependent on local trust
procedure) when they have been fully informed about the nature and length of
the procedure the chances of success and, where appropriate, the risk of
scalp metastases (Peck 2000).
Scalp cooling can be a long and uncomfortable procedure and should not be
offered unless it is beneficial or the patient insists on undergoing the
procedure even after a full explanation regarding the lack of any benefit.
Patients must also be informed that they may discontinue the procedure at
any time if they find it too physically or psychologically traumatic (Tierney
1987) or if they fail to retain hair.
Research shows that scalp cooling can be very distressing (Tierney et al.
1989) although patients still find it a worthwhile procedure to undergo,
regardless of whether or not it is successful and would have it again if
necessary (Dougherty 1996 2002). It has also been shown that the severity
and distress associated with hair loss may be less for those who use scalp
cooling (Protiere et al. 2002). Patients have reported adverse effects during
and following treatment such as headaches, claustrophobia and ice phobias
(Tierney et al. 1989; Dougherty 2002). Nurses need to understand the
meaning that hair loss has for the patient. Alopecia can cause depression,
loss of self-confidence and humiliation – it is a very visible sign of cancer.
Patients who have relapsed and are undergoing further chemotherapy which
causes alopecia may find the loss of hair a second time to be more
devastating (Gallagher 1996). It is important therefore to ensure that if a
patient fails to retain hair or decides not to undergo scalp cooling; adequate
time is spent helping the patient to adapt to the hair loss physically,
psychologically and socially. It is recommended that nursing interventions be
directed towards helping the patient and family adapt to alopecia by using
patient education, available resources and supportive listening (Pickard-Holley
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1995). This can be partly achieved by ensuring that the patient sees the
surgical appliance officer as soon as possible, in order to obtain a wig that can
be matched to the patient’s desired hair style and colour. Advice can be given
on hair care and various ideas of hats, turbans and scarves and reinforced
with a hair care information booklet (Pickard-Holley 1995; Batchelor 2001).
Procedure guidelines
The Chemocap (Intermark Medical Innovations Ltd)
A gel filled cap which is stored in a freezer at a temperature between –25o and
-32 oC. Each cap must be in the freezer for at least 12 hours prior to use.
Before commencing scalp cooling it is important to ensure the patient is aware
of the procedure, the duration of scalp cooling and the potential discomfort.
The patient must be made aware that success of scalp cooling is variable and
that it may be discontinued at any time at their request, a verbal consent to
scalp cooling is required.
The cap fits snugly over the patient’s head. A Neoprene overcap is applied
over the Chemocap to maximise adherence to the scalp, ensuring there are
no air pockets at the crown of the patients head and ears, forehead and
exposed skin need to be protected by cotton wool/gauze swabs.
The first cap must be applied a minimum of 15 minutes before the
Chemotherapy commences.
When ready to commence Chemotherapy a 2nd cap directly from the freezer
needs to replace the first cap.
Each Chemocap after the first must remain in place for 45 minutes.
The final cap can be left in place for a total of 60 minutes.
Caps require cleaning after use with a wipe or damp sponge, and returned to
the freezer.
References and further reading
Adams, L et al. (1992). The prevention of hair loss from chemotherapy by the
use of cold air scalp cooling. Eur J Cancer Care, 15, 16-18.
Batchelor, D. (2001) Hair and cancer chemotherapy. Eur J Cancer Care, 10,
147-63.
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Bulow, J. et al (1985) Frontal subcutaneous blood flow and epi- and
subcutaneous temperatures during scalp cooling in normal man. Scand J Clin
Lab Inves, 45, 505-8.
Burdine, S.A. (2001) Who Needs Hair – The Flipside of Chemotherapy. Saba
Books, Florida.
Carr, K. (1998) How I survived the fall out. You Magazine, Mail on Sunday 10
May 61-7.
Cline, B.W. (1984) Prevention of chemotherapy induced alopecia; a review of
the literature. Cancer Nurse, June 221-8.
Crowe, M., Kendrick, M. & Woods, S. (1998). Is scalp cooling a procedure
that should be offered to patients receiving alopecia induced chemotherapy
for solid tumours? Proceedings of 10th International Conference on Cancer
Nursing, Jerusalem, Abstract, p. 64.
Davis, S.T. et al (2001) Prevention of chemotherapy induced alopecia in rats
by CDC inhibitors. Science, 5 (291), 25-6.
Dean, J.C. et al (1979) Prevention of doxorubicin-induced hair loss with scalp
hypothermia. N Eng J Med, 301, 1427-9.
Dougherty, L (1996) Scalp cooling to prevent hair loss in chemotherapy. Prof
Nurse, 11(8), 1-3.
Freedman, T.G. (1994) Social and cultural dimensions of hair loss in women
treated with breast cancer. Cancer nurs, 174, 334.
Gallagher, J. (1996) Women’s experiences of hair loss associated with
chemotherapy – longitudinal perspective. Proceedings of 9th International
Conference on Cancer Nursing, Brighton, Abstract, p/ 52.
Gallagher, J. (1997) Chemotherapy induced hair loss – impact on a woman’s
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Giacone, G. et al (1988) Scalp hypothermia in the prevention of doxorubicin
induced hair loss. Cancer nurs, 11(3), 170-3.
Gregory, R.P. et al (1982) Prevention of doxorubicin induced alopecia by
scalp hypothermia: relation to degree cooling. Br Med J, 284, 1674.
Guy, R. et al (1982) Scalp cooling by thermocirculator. Lancet, 24 April, 9378.
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Hidalgo, G.M. et al (1999) A phase 1 trial of topical topitriol. Anticancer
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Kendell, P. (2001) Magic gel that helps cancer patients hold onto their hair.
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MacDuff, C., Mackenzie, T., Hutcheon, A. et al. (2003) The effectiveness of
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Parker, R. (1987) The effectiveness of scalp hypothermia in preventing
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