Scalp Cooling with Anthracyclines - Breaking Away from 'Taxanes Only'

Conversation led by Dr Julie Nangia with Mary Fay, Dr Taka Kinoshita, Dr Christian Kurbacher and Dr Jin Soek Ahn, on scalp cooling with Anthracyclines. April 2022.

Scalp cooling results with anthracycline regimens are often significantly lower, with around 30% chance of retaining 50% of hair in comparison to taxane retention rates, which are a 75-80% chance of retaining 50% of hair. Despite this, is it time to break away from the ‘taxanes only’ mentality and improve scalp cooling practice, ensuring that patients on anthracycline regimens are also given scalp cooling as an option? Increased patient education allows for informed decision making, ensuring that scalp cooling is a choice made by the patient, rather than by the physician. 30% hair retention may not be enough for a physician, but it can be significant for a patient.

"Increased hair regrowth rates really was our pitch to help some of our oncologists who were less optimistic about scalp cooling with anthracyclines"

Mary Fay, RN
  • Scalp cooling should be offered to all patients, including those on anthracycline and combination chemotherapy regimens 
  • Success is subjective – hair retention rates that might be seen as a failure by a physician, may be seen as successful by a patient
  • Increased regrowth with scalp cooling means that the treatment can show long term benefits beyond managing hair loss, which can motivate patients to continue with scalp cooling and help patients move on from treatment faster  

‘It’s not easy to get physicians to change their prescribing as it puts people way out of their comfort zones’ – Mary Fay

For clinicians, scalp cooling is usually seen as having a binary outcome – majority of hair retained equals a success, majority of hair lost therefore is deemed unsuccessful. But for patients, perceived hair retention outcomes can be more nuanced than this. The opportunity to prevent 100% hair loss can make scalp cooling valuable, and most importantly should be the choice of the patient. 

Additionally, there is now significant data demonstrating the increased rates of hair regrowth that results from the continuation of scalp cooling, even when significant hair loss has been sustained on regimens such as anthracyclines. The proposition is that it’s time to change the way scalp cooling is approached, as the advantages are not just about the short term benefits and hair retention, but also in the longer term with increased rates of regrowth, aiding a patient’s ability to move on from the impact of chemotherapy treatment.

Simultaneously, counseling the patient to ensure realistic expectations is important, particularly with anthracycline regimens. While this can add time on to already stretched schedules, being open and honest with patients is essential to positive outcomes. Scalp cooling won’t be for everyone, but this does not mean the option should not be offered. 

‘Any amount of hair retention is pretty significant for patients’ – Dr Julie Nangia

Another discussion topic is that drug sequencing can make a significant impact on the rate of hair retention with combination regimens. For example, several studies have shown that administering taxane chemotherapy first has seen a positive impact on resulting hair retention. It allows a patient to master cap fitting when the risk of hair loss is lower, and the thinning that occurs with taxanes reduces the insulation effect of thicker hair, allowing for more efficient cooling by the time the patient receives anthracyclines. 

It is also important to note that administering anthracycline drugs first will see higher rates of hair loss at the earlier stages of treatment, but does allow for potential regrowth during the taxane phase of treatment before the end of chemotherapy. More research is required, but where possible, switching sequencing according to the patient’s priorities is worth considering. 

Other areas which would benefit from more research include: 

  • The impact of lowering cooling temperatures to improve efficacy, particularly with anthracycline regimens
  • Whether extending cooling times would improve efficacy – though this would inevitably add to chair time, which could be challenging
  • Investigating which anthracycline drugs show the best rates of retention with scalp cooling

By not offering scalp cooling to patients who will be receiving an anthracycline regimen, clinicians are taking away an important supportive cancer care measure. While it is important that patients are appropriately educated to ensure informed decision making and set realistic expectations, the choice should ultimately be in the hands of the patient. There are also significant, nuanced scalp cooling studies that clinicians need to familiarize themselves with, in order to support patients more effectively and increase scalp cooling usage. 

Kinoshita T, et al. Efficacy of Scalp Cooling in Preventing and Recovering From Chemotherapy-Induced Alopecia in Breast Cancer Patients: The HOPE Study. Front Oncol. 2019 Aug 6;9:733. 

Ohsumi S, et al. Scalp cooling for hair loss prevention in female Japanese breast cancer patients receiving (neo)adjuvant chemotherapy. Support Care Cancer. 2021 Jan;29(1):437-443.

van den Hurk CJ, et al. Scalp cooling for hair preservation and associated characteristics in 1411 chemotherapy patients – results of the Dutch Scalp Cooling Registry. Acta Oncol. 2012 Apr;51(4):497-504.

Rice BA, et al. Registry study to assess hair loss prevention with the Penguin Cold Cap in breast cancer patients receiving chemotherapy. Breast Cancer Res Treat. 2018 Jan;167(1):117-122.