Cold Comfort: How Scalp Cooling Can Preserve a Cancer Patient's Hair

For many, going bald is one of the most distressing side effects of chemotherapy, and that’s why scalp-cooling technology is growing in popularity. Devices known as cold caps can safely help patients undergoing treatment for solid tumors to keep more of their hair.

A recent randomized clinical trial tested the technology in 236 patients being treated for breast cancer. In 184 patients who could be evaluated, researchers found that, after a median of four cycles of chemotherapy, 50% of women who used the devices kept their hair; among those who took a less aggressive chemotherapy regimen, about two-thirds avoided hair loss.

Meanwhile, women who did not use the caps lost all or most of their hair. In an interview with CURE ^®, breast cancer specialist Dr. Julie Rani Nangia, the lead investigator of the 2017 study and an assistant professor at Baylor College of Medicine in Houston, Texas, discussed the effectiveness, safety and availability of scalp cooling.

CURE®: How do cold caps work?

Nangia: The companies Dignicap and Paxman have received FDA approval for very similar scalp- cooling systems. These basically include a mini refrigeration unit that attaches to a cold cap and circulates a coolant, which keeps the cold temperature at a constant level on the scalp.

These systems are different from the caps you put in the freezer and then put on, which aren’t attached to anything. But in either case, the cold temperature constricts the blood vessels in the scalp and lowers the amount of chemotherapy delivered to the hair follicles.

It also decreases the protein and enzyme activity in the hair follicles, so the chemo that is delivered may not work as efficiently there.

Could protecting the follicles from chemotherapy leave the scalp vulnerable to the spread of cancer?

As far as safety goes, quite a few very large studies show that if people use scalp cooling, there is no apparent difference in how long they live or whether cancer will recur in the scalp (compared with patients who don’t use cooling caps). This is true for patients with solid tumors such as breast, lung and ovarian cancers.

Some cancers spread through the bloodstream, such as leukemias and lymphomas; for those types of cancers, these devices may not be safe.

How long do patients need to wear cold caps?

Patients need to start using cold caps with their first chemotherapy infusion because sometimes even after one infusion, hair can fall out.

The recommendation is to wear the cap at least 30 minutes before starting each infusion. Some data suggest that if someone has really thick hair or is African American, a 45-minute precooling time may be more effective.

Patients use scalp cooling for the duration of each chemotherapy session, and then a post- cooling time varies from 30 to 90 minutes after infusion, depending on the drug being used.

What percentage of hair do patients typically retain when they use scalp cooling?

This depends on two main factors: the type and duration of chemotherapy.

With a chemotherapy called paclitaxel, the retention rate with scalp cooling was 100%. We define “hair retention” as losing less than 50% of your hair and not needing a wig or other covering. With anthracycline chemotherapies like Adriamycin (doxorubicin), in our study, the hair retention rate was around 20%.

However, a couple of studies after ours found that if patients need both types of chemotherapy, giving the full course of paclitaxel before starting the anthracycline brings the hair retention rate closer to 40% The second factor is the fit of the cap, which is really important, because if you have areas where there’s no contact, you lose hair in those areas. We recommend that patients not have any braids, weaves or extensions, because that can prevent effective cooling.

We don’t have a very good cap that fits the Japanese skull, which is a different shape, so Japanese women tend not to have good luck with hair retention. One of the companies is actually developing a specific cap for Japanese women. Ideally, one day, we’ll get to a point where 3D laser printing is not that expensive, and we can literally make personalized caps for patients.

What kinds of side effects do people experience from scalp cooling?

The caps are well-tolerated, and most people in our study rated the devices as comfortable.

The most common reasons for discontinuing use of the device was that people felt claustrophobic or too cold or uncomfortable. We can give patients a little anxiety medicine beforehand, which can help.

Some people get cold-induced migraines, and those women in our study really did not tolerate the device. However, I have had people who wanted to try it despite having a history of migraines, and they just took their migraine medicine before using it and were fine.

The other most common side effects were maybe a little bit of discomfort from the cap’s fit, but we can use headbands and gauze to make it more comfortable.

How widely available is scalp cooling?

Some cancer centers lease the devices and then patients pay to use them. Paxman right now is in 40 states and 330 locations, and Dignicap is in 30 states and 170 locations. That’s actually not a lot. If you’re going to a bigger center, you’re more likely to have access. The Rapunzel Project (rapunzelproject.org) lists locations that offer scalp cooling.

The other option is to rent cold caps outside the cancer center (for instance, Penguin Cold Caps). The patient brings a cooler with dry ice and several caps that are switched out during the treatment, so there is always a cold one available.

These systems are more labor-intensive, but they do appear to be equally effective in terms of hair retention and work out to around the same price as the ones available through cancer centers.

Are cold caps usually covered by health insurance?

Not always, so finances are a big problem. In the grand scheme of cancer treatments, these devices don’t cost that much. At between $1,500 and $2,000, they’re less than the cost of an MRI, and one of the companies has a maximum lifetime cost cutoff of $2,200.

About 20% of patients can get reimbursed through insurance now, and the amount varies from 10% to 100%. Both Paxman and Dignicap are trying to help get reimbursement because these devices provide a needed service. It’s comparable to nausea from chemotherapy: We’re not going to refuse to give patients a nausea drug. A lot of people used to think that breast reconstruction was optional because it was cosmetic, but data showed that it had a huge psychological impact.

The same kind of data are emerging about chemotherapy-induced alopecia. It’s not just about vanity; it’s about emotions, psyche, body image and being able to live a normal life and not feel like a sick person all the time. Some patients even decline chemotherapy specifically to avoid hair loss and perceive it to be a stigma. So, I really do think insurance will eventually pay for these in full.

In the meantime, a few organizations offer subsidies or assistance for scalp cooling. Hair to Stay (hairtostay.org) is the biggest national one, and I’ve had a lot of patients who received some financial support through them.

Some patients are never told that cold caps are an option, even if their treatment centers offer the devices. What can be done to raise awareness?

Oncologists need to know about this technology and offer it to patients, yet a lot don’t know the data. When publications like CURE® highlight studies about scalp cooling, patients go and ask their oncologists, and that helps. I have educated peers by conducting grand rounds, and centers can also help by offering information about scalp cooling as part of the chemotherapy education routinely given to patients.

One positive thing that has happened is that the National Comprehensive Cancer Network, which comes out with guidelines for cancer care, has issued a recommendation to consider scalp cooling in treatment for breast and ovarian cancer. It would be wonderful if we could get that recommendation for all solid tumors, because that’s what the devices are approved for.