Richard B. Schwab, MD. Associate Clinical Professor of Medicine, Moores Cancer Center, University of California, San Diego, School of Medicine
Q: Loss of hair is a predictable adverse effect of much chemotherapy. Although “only cosmetic” this can be a troubling event for some patients. What is your opinion about the new devices or methods available to diminish chemotherapy-induced alopecia?
A: Scalp cooling to reduce chemotherapy-induced alopecia has been available for many years. This approach is effective for taxane-based chemotherapy regimens and, in my experience, can have benefit even with anthracycline-based regimens. There is good safety data for acute toxicity (for example frostbite hasn’t been an issue) but there is no good data on how exclusion of chemotherapy from the scalp might affect the risk of recurrence in this area of the body. Fortunately scalp recurrences are extremely rare, which is the major reason why data on scalp recurrence risk with cooling is not likely to ever be available. Regardless, I always educate my patients about this hypothetical risk. Given that the benefit of adjuvant chemotherapy for some breast cancer patients can be modest, this approach to reduce toxicity is quite reasonable.
In the past Penguin Cold Caps were used by some of my patients, under their own arrangements. This approach is quite burdensome requiring patients to bring in caps on dry ice and have an assistant with them to exchange these caps frequently during the infusion, and for some hours after as well. The total duration of recommended use varies with chemotherapy regimen but is about 5-6 hours per treatment. More recently Dignitana has obtained FDA approval for their system. The advantage of their system is that cap exchanges are not needed. A disadvantage is that centers offering this system need to lease a machine and thereby become involved in the business of scalp cooling. Given that insurance rarely reimburses any costs associated with the treatment of chemotherapy-induced alopecia this is a significant issue. Patients can expect to pay approximate $500 per treatment so a typical course of chemotherapy, with 4 treatments, scalp cooling will cost an additional $2000.
Now centers must consider how to handle scalp cooling. If a center leases a Dignitana system there will be a financial incentive for utilization. Additionally centers will need to consider how to handle this for patients that cannot afford the added cost. Is reduction of hair loss a good use of limited charity resources? Additionally logistical issues could develop. Each system can only accommodate 2 users at a time so patients using this system will face additional scheduling limitations. Is waiting to start chemotherapy at a time when scalp cooling is available acceptable or will additional systems need to be leased to prevent delays in therapy?
Obviously numerous additional questions will arise if scalp cooling becomes more popular. For now, it seems to me that this is a good thing for our patients. Fortunately cure rates for breast cancer patients are relatively high and are rising. This gives us the luxury to focus more and more on reducing the toxicity of breast cancer treatment. Scalp cooling is undoubtedly an effective way to reduce one of the most troubling toxicities of chemotherapy for our patients.
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