Do Quality of Life Measurements Need to Evolve to Reflect the Impact of Hair Loss During Chemo?

Conversation led by Professor Fran Boyle with Dr Steven Isakoff, Dr Amie Jackson, Trisha Marsolini and Isa Pupo Wiss. March 2022

Many controlled trials that have examined the impact that scalp cooling can have on a patient’s quality of life versus those who don’t scalp cool, have found little if any difference in the patient’s experience. For those who are providing supportive care, including scalp cooling, to cancer patients, these findings aren’t representative of what they see in clinic. Is it time to review the scales used to examine quality of life (QoL), and acknowledge that there isn’t a scale which precisely reflects the impact chemotherapy-induced alopecia (CIA) has on self-confidence, physical appearance and mental well-being?

"What success looks like is not your hair looking as nice as it did on the day of the consult, so sometimes that fear of on-going hair loss or that feeling of “is it really working?” is something you want to set expectations well for at the start of the therapy to maximize benefit"

Dr Amie Jackson, MD
  • There is plenty of data on the impact of hair loss as a result of chemotherapy, but studies have largely shown little difference in a patient’s quality of life with scalp cooling versus those without
  • Quality of life scales have historically successfully tracked patient experience, but are now not measuring the details required to reflect the advances in side effect management 
  • Accurate quality of life measurements will be different for each patient and accounting for these nuances is challenging  

Increased hair regrowth rates with scalp cooling have been predicted based on anecdotal experience for some time, but now there is a range of clinical data to support this. Patients have always been motivated by the prospect of reduced and/or delayed alopecia with scalp cooling, but there was little awareness of the enhanced rates of regrowth until they experienced it first-hand – allowing them to return to normal as quickly as possible after chemotherapy treatment. 

It is also important to note that the benefits of hair retention and regrowth are not mutually exclusive – even patients who see significant hair loss can also see increased rates of regrowth. This is particularly important for those patients who receive regimens such as anthracyclines, where higher rates of retention are more challenging. 

Enhanced regrowth at certain stages of treatment also allows for personalized regimen sequencing, to manage if and when patients’ experience hair loss, as well as when they may see regrowth. It has also been noted that there is evidence to suggest that the sequencing of combination regimens can have an impact on retention rates. It has been proposed that when taxanes are given first, there are noticeably higher rates of hair retention by the end of chemotherapy, as the cytoprotective nature of scalp cooling has helped to preserve their hair follicles ready for the anthracycline rounds. However, even for those patients that receive anthracycline regimens first, the use of scalp cooling has the potential to allow regrowth through the taxane phase, allowing patients to see close to normal rates of hair density before the end of chemotherapy. This highlights the need for more research to understand fully the impact that sequencing will have when it comes to hair retention with scalp cooling.

‘If their hair regrowth rate can be enhanced by the time they complete both phases of chemotherapy, the sooner they are able to go back to their normal lives… it is a very important milestone’ – Dr Jyoti Bajpai

Managing patient’s expectations and effective precision medicine counseling is imperative when it comes to ensuring the continuation of scalp cooling if a patient has experienced poor hair retention. This support can be exercised in three stages: 

Firstly the physician can introduce scalp cooling and moderate expectations around retention rates based on regimen, and introduce the concept of faster regrowth

Secondly, nursing teams who have greater contact with the patient during their chemotherapy regimens can continue the regrowth dialogue, manage their expectations accordingly, and address concerns

Thirdly, peer to peer support opportunities are vital in providing additional support and encouragement, as patients who are ahead in the process can share their experiences with those beginning treatment

There is no doubt for those who provide scalp cooling that the treatment has a positive impact on a patient’s experience of chemotherapy and quality of life. By ensuring that clinicians are taking in to account the increased rates of regrowth that scalp cooling can provide, it is possible to provide another tool for carefully managing expectations and helping to encourage continuation of scalp cooling.

Bajpai J, et al. “Randomised controlled trial of scalp cooling for the prevention of chemotherapy induced alopecia”. Breast. 2020 Feb;49:187-193.

Ohsumi S, et al. Prospective study of hair recovery after (neo)adjuvant chemotherapy with scalp cooling in Japanese breast cancer patients. Support Care Cancer. 2021 Oct;29(10):6119-6125.

Episode 2 – Changing the Face of Cancer Podcast. Why we need to be taking about hair regrowth, not just hair retention. With Dr Bajpai and Professor Toi.

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.