I RESEARCH I

The prevention of hair loss from chemotherapy by the use of cold-air scalp- cooling

LYNN ADAMS, NORA LAWSON, K. J. MAXTED AND R. P. SYMONDS

The use of a cold-air scalpcooling system to prevent alopecia following administraton of anthracycline chemotherapy is described. The unit used is mounted on a four-wheeled trolley and is highly mobile. Twenty-four patients with advanced breast cancer received epirubicin chemotherapy, 14 at a dose of 50 mg/m2, and 10 at a dose of 100 mg/m2. All 10 patients receiving 100 mg/m2 developed total alopecia; by contrast, only two out of 14 receiving 50 mg/m2 had alopecia, while the remaining 12 retained their hair. Patients not receiving scalp-cooling inevitably developed total alopecia after three pulses of epirubicin.

IIltrOdUCtiOIl

Alopecia (hair loss) is an almost inevitable side- effect of chemotherapy treatment with the anthracycline group of drugs (doxorubicin and epirubicin) often used to treat breast cancer. Hair loss is probably the most distressing side-effect of this type of chemotherapy and may lead some patients to refuse the very treatment that may provide useful palliation and disease control.

Anthracycline-induced hair loss can be prevented by scalp-cooling (Anderson et al., 1981; Satterwhite, 1984). Uptake of the drug into hair follicles is reduced by cutaneous vasoconstriction and by the inhibition of temperature-dependent metabolic pathways into the cell. As the anthracyclines are rapidly excreted following bolus injection, scalp-cooling need only be applied for a relatively short period of time (Benjamin er al., 1974).

Poor conductivity is a problem common to the three major methods of scalp-cooling currently in use:

c cryogel (Dean er al., 1983) 8 ice packs (Anderson er al., 1981) o cooled water (Guy er al., 1988).

If the scalp-cooling apparatus is ill-fitting, contact may be poor in certain parts of the scalp and cooling will be non-uniform. The hair has to be wet to improve conductivity, and the scalp must be bandaged to improve the fit. Melting ice and cryogel may not provide uniform cooling because the separating phases are not activity-

mixed. In addition, these devices are heavy and require storage in a deep-freeze.

Scalp-cooling from the ‘Kold-Kap’ is probably superior to an ice pack (Dean et al., 1979). The ‘Kold-Kap’ cools the scalp by the initiation of an endothermic reaction when water is added to ammonium nitrate within the device. It is smaller and lighter than a cryogel pack but suffers from the Same potential problem of poor conductivity and has a limited refrigeration capacity.

In contrast, cold air offers more uniform cooling of the scalp at a constant rate. Insulation by the hair is a minor problem, overcome by a sufficient flow to promote turbulence. Wetting of the hair is not necessary.

Over the past five years we have refined a system in which refrigerated air is passed over the patient’s scalp via a hair-dryer helmet. A previous study conducted in the department (Symonds et al., 1986) reported on the effectiveness of this system. Sixteen out of 26 patients in whom scalp- cooling was performed had no hair loss, four had slight hair loss and six required a wig. Of the 26 patients, four out of four patients treated with ABVD for Hodgkin’s disease, and nine out of 13 treated with adriamycin (40 mg/m2) and vincristine (2 mg) for breast cancer, had no hair loss.

The overall results of t h i s method of scalp- cooling compare favourably with other published series (Edelstyn er al., 1977). Many of the patients reported received other epilatory agents

16 Eurc~peanJaunral of Cancer Care 1.5, 1992

along with adriamycin such as cyclo- phosphamide. The good result in the Hodgkin’s group may be in part due to the low dose of adriamycin (25 mg/m2) used, but the hair preservation in the breast group is superior to that previously reported (Gregory et al., 1982) using cryogel to scalp-cool patients treated with the same chemotherapy regimen.

The system currently in use generates cold air from refrigeration components mounted in a four-wheeled trolley (see Fig. 1). The unit is highly mobile and is powered from a standard 13-amp plug. Previously we used an air compression and a vortex tube to generate cold air. This restricted the use of the unit to within 30 metres of the compressor. The system, although effective, was noisy and produced air with a slight oily smell. In comparison, the current unit is quiet and produces air that is odour-free. After 15 minutes of scalp-cooling, the scalp temperature measured by a thermocouple on the scalp insulated by ‘blue-tack’ was reduced to 18-22°C.

Twenty-four patients treated with epirubicin for advanced breast cancer received scalp- cooling. Ten patients received a dose of 100 mg/m2, and 14 a dose of 50 mg/m2. Air at a temperature of about 2°C was passed over the scalp via a helmet supported by a counter- weighted stand. The helmet was lowered on the head until three rubber stops were in contact with scalp. Air leakage was reduced by a nylon skirt which closed the gap between the helmet and the head. Gauze swabs were applied to the ears to protect against the cold air. Scalp-cooling was applied for 15 minutes before and 30 minutes after the bolus injection of chemotherapy.

Hair loss was graded as follows: 0 = no hair loss, 1 = slight hair loss (no wig required), 2 = moderate patchy hair loss (wig required), and 3 = complete alopecia (wig required). Hair loss was recorded following each pulse of chemotherapy, and Polaroid photographs were taken before chemotherapy and after every third pulse of chemotherapy.

Each patient received at least two pulses of epirubicin. Scalp-cooling as given was ineffective at a dose of 100 mg/m2, and all 10 patients developed total alopecia after two or three pulses of chemotherapy. In contrast, scalp-cooling was highly effective when a dose of 50 mg/m’ was administered. Only two out of 14 patients

developed total alopecia. Twelve patients had minimal or no hair loss and did not require a wig. Patients kept their hair after up to 16 pulses of chemotherapy (mean number of pulses = 6). Patients receiving scalp-cooling were a subgroup of a much larger number entered into a trial to examine the effects of epirubicin against breast cancer at two dose levels. Patients not receiving scalp-cooling inevitably developed total alopecia after three pulses of epirubicin at 50 mg/m*. It was interesting to note that patients for whom scalp-cooling preserved scalp hair, lost pubic and axillary hair. Scalp-cooling was found to be acceptable by all 24 patients treated and none refused further scalp-cooling.

Fig. 1. The cold-air S C d P - C O O U system in use*

Cold air has intrinsic physical advantages over older methods of scalp-cooling such as ice packs, cold water, cryogel or the ‘Kold-Kap’. The devices are heavy, the hair has to be wetted to improve conductivity, and the scalp must be bandaged to improve the fit.

A cooling time of 30 minutes is sufficient in most patients to prevent alopecia when medium doses (50 mg/m2) of epirubicin are given. One reason for the failure to preserve hair when high doses (100 mg/m2) are given is the relatively short period of scalp-cooling. At the end of cooling significant quantities of the drug, sufficient to cause hair loss, may remain in the blood. Measurements of the serum drug level at the beginning and end of scalp-cooling are currently in progress to try to determine the optimum duration of cooling when high doses of the drug are given.

E u r o p e a n J m l of Cancer Care 1.5, 1992 17

References Anderson H.E., Hunt J.M. & Smith I.E. (1981)

Prevention of doxorubicin induced alopecia by scalp cooling in patients with advanced breast cancer. British MedicalJournal, 282,423-424.

Benjamin R.S., W i d P.H. & Bachur N.R. (1974) Adriamycin chemotherapy - efficacy, safety and pharmacological basis of an intermittent single high dosage schedule. Cancer, 33,19-27.

Dean J.C., Grifiith K.S., Cetas T.D., Mackel C.L., Jones S.E. & Salmon S.E. (1983) Scalp hypothe& a comparison of ice packs and the Kold Kap in the prevention of doxorubicin-induced alopecia. Journal of Clinical Oncology, 1,33-37.

Dean J.C., Salmon S.E. i? Griffith K.S. (1979) Prevention of doxorubicin-induced hair loss with scalp hypothermia. New England Joutnal of Medicine, 301,1427-1429.

EdelstynG.A.,MacDonaldM. &MacRae J.D.(1977) Doxorubicin-induced hair loss and possible modi- fication by scalp cooling. Lmrcet, 2,253-254.

Gregory R.P., Cooke T., Middleton J., Buchanan R.B. & Williams C.J. (1982) Prevention of doxorubicin-induced alopecia by scalp hypo- thermia: relation to degree of scalp cooling. British MedicalJournal, 284,1674.

Guy R., Parker H., Shah S. & Geddes D. (1988) Scalp cooling by thermwirdator. Lancer, 1,937-938.

Satterwhite B. & Zimm S. (1984) The use of scalp hypothermia in the prevention of doxorubicin induced hair loss. Cancer, 54,3437.

Symonds R.P., McCormick C.V. & Maxted K.J. (1986) Adriamycin alopecia prevented by cold air cooling. Amet.ican Journal of Clinical Oncology, 9, 454457.

Lynn A d m and Nora Lawson are Clinical Nurse Specialists, and R . P . Symonds is Consultant in Radwtherapy and Oncology, at the Beatson Oncology Centre in Ghgm, UK. K. 3. M a t e d is Primpal Senior Physicist at the West of Scotland Health Board's Department of Clinical Physics and Bio-Engimering, Ghgm, UK.

HeaBh Care Research by Degrees is primarily concerned with those undertaking projects within degree and diploma courses and is illustrated throughout with examples from nursing, physiotherapy, occupational therapy and radiography. Those who carry out research within their professional role will also find that the book meets their needs.

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18 European Journal of Cancer Care 1.5, 1992