The Importance of Protocols in Achieving Efficacious Scalp Cooling

Conversation led by Dr Lindsay Peterson with Dr Steven Isakoff, Elisa Mills, Mikel Ross and Dr Corina van den Hurk on scalp cooling protocols. April 2022.

Scalp cooling isn’t quite as easy as putting on the cap and plugging in to the system, though it’s not far off! Adhering to a simple protocol process will ensure the best possible efficacy and hair retention, as taking shortcuts can have a real impact on a patient’s outcomes. So what are the easily applicable hints and tips that help to achieve best practice in clinic?

"We talk to our patients a lot about being self-empowered – this is your opportunity to really self-manage this and take some responsibility in terms of the outcome"

  • Scalp cooling can be challenging to integrate into busy oncology clinics, but following tried and tested workflows/protocols means that scalp cooling can work effectively for patients and clinicians 
  • Interdisciplinary buy-in and detailed workflows which are based on collected data are the key to integration
  • Managing patient expectation and emphasizing the importance of education and pre-treatment preparation is essential to effective hair preparation and cap fitting

‘Everyone has a role in scalp cooling – the patient, the nursing team and the physician’ – Dr Lindsay Peterson  

Scalp cooling is another addition to an already busy oncology clinic, but cutting corners only leads to less effective scalp cooling, that doesn’t serve the patient or the clinician. Successful integration of scalp cooling in to clinical practice is aided by an interdisciplinary workflow, which establishes a scalp cooling introduction with the patient, sets appropriate expectations around efficacy and the process itself, sizing the patient for the cap, and encouraging the patient to engage with educative materials and practice before the first treatment. Preparatory work with the patient not only improves experience but their outcome, and thereby reduces the workload on clinical teams as patients can then often self-manage through the hair preparation and cap fitting process.

While it isn’t often a formalized protocol, counseling the patient to ensure realistic expectations is important. This can add time on to already stretched schedules, however, being open and honest with patients is essential to positive outcomes. Unrealistic ideas of hair retention and a lack of understanding of the scalp cooling process is likely to lead to unhappy and dissatisfied patients. Scalp cooling won’t be for everyone, but this does not mean the options should not be offered.    

Another recommendation is tracking scalp cooling results to inform workflows, to improve practice, to inform clinical team expectations, and identify best practice. The Dutch Scalp Cooling Registry has expanded to an international platform to begin facilitating this.

‘It’s about information provision. It’s about cap fitting and hair care’ – Dr Corina van den Hurk 

Logistical considerations are key to successful scalp cooling – effective chair time scheduling, order sets for pre-scalp cooling analgesia, and separate post-cooling areas, can all help to manage adding scalp cooling as a standard care. Extended chair time requirements can be challenging but not something that is insurmountable. 

As well as these logistics, not giving appropriate consideration to cooling times, hair preparation and cap fit, can have a significant impact on hair retention rates.  This poor efficacy leads to unhappy patients, disengaged and demotivated clinical staff, and ultimately a decline in the use of scalp cooling.  

While there is a learning curve with scalp cooling, for clinical teams and for patients, ensuring  protocols and workflows are fine-tuned and adhered to, and patients are empowered to educate themselves and their expectations are successfully managed, will mean positive outcomes and good rates of hair retention are achievable. 

Peterson LL, et al. Integration of Physician and Nursing Professional Efforts to Deliver Supportive Scalp Cooling Care to Oncology Patients at Risk for Alopecia. Oncol Ther. 2020 Dec;8(2):325-332.

Fischer-Cartlidge E, et al. Scalp Cooling: Implementation of a Program at a Multisite Organization. Clin J Oncol Nurs. 2018 Oct 1;22(5):534-541.

Komen MM, et al. Results of 20- versus 45-min post-infusion scalp cooling time in the prevention of docetaxel-induced alopecia. Support Care Cancer. 2016 Jun;24(6):2735-41.

van den Hurk CJ, et al. Learning from best scalp cooling practices in a registry: Differences in results from n>7000 patients with solid tumors. Journal of Clinical Oncology 2019 37:15_suppl, 11610-11610.

Rugo HS, et al. Association Between Use of a Scalp Cooling Device and Alopecia After Chemotherapy for Breast Cancer. JAMA. 2017;317(6):606–614.

van den Hurk CJ, et al. Short post-infusion scalp cooling time in the prevention of docetaxel-induced alopecia. Support Care Cancer. 2012 Dec;20(12):3255-60.

van den Hurk, et al. (pre-)Clinical research to understand alopecia and improve cooling results. Netherlands Comprehensive Cancer Organisation, 2015.

Information on the International Chill Registry.