Clinical Question: Does scalp-cooling reduce alopecia in cancer patients receiving chemotherapy? Articles

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Scalp Cooling and Alopecia
Appraised by:
Kristi Erickson SN, Megan Hilzendeger SN, Lauren Ritter SN

NDSU College of Nursing at Sanford Health, Bismarck, ND

Clinical Question:
Does scalp-cooling reduce alopecia in cancer patients receiving chemotherapy?
Betticher, D. C., Delmore, G., Breitenstein, U., Anchisi, S., Zimmerli-Schwab, B., Müller, A., &

Trueb, R. R. (2013). Efficacy and tolerability of two scalp cooling systems for the

prevention of alopecia associated with docetaxel treatment. Supportive Care In

Cancer. 21(9), 2565-2573. doi:10.1007/s00520-013-1804-9
Kargar, M., Sarvestani, R. S., Khojasteh, H. N., & Heidari, M. T. (2011). Efficacy of penguin

cap as scalp cooling system for prevention of alopecia in patients undergoing

chemotherapy. Journal Of Advanced Nursing67(11), 2473-2477. doi:10.1111/j.13652648.2011.05668.x
Mols, F., van den Hurk, C., Vingergoets, A., Breed, W. (2008). Scalp cooling to prevent

chemotherapy- induced hair loss: practical and clinical considerations. Support Care

Cancer, 17, 181-189. doi: 10.1007/s00520-008-0475-4
Synthesis of Conclusions:

Betticher, et. al. (2013) conducted a non-randomized prospective controlled study at twenty-seven sites in Switzerland. Two hundred thirty eight cancer patients receiving chemotherapy infusions were studied. Participants in the study were given the ability to choose which of the three treatments that they preferred from the options of 1) PAX (Paxman electric cooling device), 2) CC (gel-filled cooling caps), and 3) no scalp cooling treatment (the control group). There were 39 participants who received no treatment in the control group. The cooling caps were placed on the participants for 30 minutes before chemotherapy infusion start time, the duration of the chemotherapy infusion, and for either 45 or 90 minutes post-infusion end time. There was no significant difference whether patients wore the scalp cooling treatment for 45 or 90 minutes after the infusion was finished. For this reason, it is recommended that post infusion cooling cap time is 45 minutes as there was no significant difference in alopecia when the cap was applied for the extra 45 minutes totaling 90 minutes. The findings in this study show that patients receiving docetaxel therapy with both PAX and CC devices substantially reduces alopecia compared to patients receiving docetaxel and no scalp-cooling technique. The participants who received the scalp cooling treatments were asked to fill out a short questionnaire after each treatment. The survey showed patient satisfaction and that there were minimal side effects of the cooling cap. Side effects included minor headaches and a small bout of chills which were relieved by warm blankets. This study has sufficient sample size for the study design. The researchers also had adequate control. The research included a definitive conclusion that supports scalp cooling during chemotherapy infusion reduces the risk of alopecia. The limitations of this study include the non-randomization, thus making it prone to selection and allocation biases because patients were free to choose their preferred treatment method. Also, the number of patients participating in the cooling cap was lower than expected due to preference to the packs treatment.

Kargar, Sabet, Khojeasteh, and Heidari (2011) conducted a non-randomized quasi-experimental study at Namazi hospital. The study included 63 patients undergoing IV chemotherapy that included six cycles of chemotherapy at intervals of 3 weeks. Thirty-one participants who accepted the scalp-cooling system were selected non-randomly and compared to 32 participants who refused the device. Interventions included Penguin caps previously kept at -20 degrees Celsius for 24 hours. They were applied to the scalp 15 minutes before chemotherapy and maintained “in situ” (Kargar, et. al. 2011) throughout the treatment period. As a result, each cap was used for an estimated 45 minutes. A check list and demographics were performed during the treatment and a nurse recorded the data. Post-procedure, the patients were assessed by a physician and the degree of alopecia was determined according to World Health Organization guidelines. The results of this study “clearly demonstrated the efficacy of the Penguin Cap to reduce alopecia.” (Kargar et. al. 2011). According to the study by Kargar et al. (2011), “24 participants treated by chemotherapy drugs and the penguin caps had alopecia of first and second degrees; significantly less severe than those receiving chemotherapy treatment without the Penguin caps” (p. 2475). This study has generalizable results and the researchers had adequate control. The sample size, however, was small and therefore limited the results.

Floortje, van den Hurk, Vingerhoets, and Breed (2008) conducted a nonrandomized, quasi-experimental study using 13 different hospitals in the Netherlands. The purpose of this study was to determine the effectiveness of scalp-cooling in patients undergoing chemotherapy as well as the burden of patients losing their hair and how it effects their body image. The study was conducted between October 2004 and February 2007. Of the thirteen hospital locations, 6 offered scalp-cooling, while the other 7 did not. Patients that decided to participate in the study receive a set of questionnaires, before the start of chemotherapy, 3 weeks after the last chemotherapy cycle, and 6 months after the last chemotherapy cycle. Ninety-eight patients received scalp-cooling while 168 control patients included were treated in hospitals with no scalp-cooling. Scalp-cooling showed to be effective in reducing chemotherapy induced alopecia in 32-62 evaluable patients while all patients in the control group not receiving scalp-cooling needed to wear a wig or head cover after completing chemotherapy. When answering questions on the questionnaire, 71% of patients didn’t feel attractive because of their hair loss. (Floortje et. al. 2008). The results of this study showed that hair loss can be stressful and this method is effective and is well tolerated.

All three studies showed evidence that scalp-cooling can reduce chemotherapy induced alopecia. Each study used a type of survey or questionnaire, and two studies used the guidelines from the WHO to determine alopecia severity.

little evidence was found regarding the negative effects of scalp-cooling. Side effects to the scalp-cooling systems were possibility of headaches and overall feeling of being cold, and the fact that it might not be effective. Only one of the three studies used a physician assessment. Sample sizes varied among the studies which limited information due to small sample sizes, but they still came to similar conclusions: scalp-cooling is effective in the reduction of alopecia in patients receiving chemotherapy.

Bottom Line:

Evidence based research shows that scalp-cooling therapy during chemotherapy infusions is found to be a safe and effective treatment for the reduction of alopecia that is a common side effect. By reducing alopecia, cancer patients receiving chemotherapy have a greater self-esteem and self-worth that is sometimes lost due to the outward physical symptoms caused by the chemotherapy.

Implications for Nursing Practice:

Nurses and Oncology staff will be able to offer scalp-cooling as an adjunctive treatment therapy for cancer patients receiving chemotherapy. By accepting this treatment modality, patients will have the option to reduce the risk of alopecia, which is a common side effect of chemotherapy. By reducing alopecia, cancer patients are able to experience a greater self-esteem, which is sometimes lost related to the alopecia. The studies appraised suggested that scalp-cooling an effective intervention.
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