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OVER the past decade, we have witnessed a significant shift towards a patient-centred approach to cancer care, and nowhere is this more apparent than in the care of patients with breast cancer.
An integrated model of breast cancer care has now evolved, where significant attention is paid to the psychosocial impacts of treatment, quality of life, patient advocacy, and survivorship. While the physician–patient relationship continues to play a critical role in care pathways, we are seeing nurses, patient support staff, and allied health professionals play a more active role in providing specialised support to patients undergoing treatment for breast cancer.
Modern integrative breast cancer care models draw on both conventional and holistic approaches to therapy, focusing on each patient as an individual and supporting them with their physical, emotional, spiritual and social needs throughout treatment. Integrated care looks beyond the physical needs of patients to focus on the emotional wellbeing of individuals throughout all stages of the treatment journey.
Psychosocial impact of hair loss in breast cancer patients
One of the most distressing aspects of treatment for many breast cancer patients is chemotherapy-induced alopecia, which is a common and unpredictable side effect of cancer treatment, with an overall incidence of about 65%.
Historically, hair loss has been one of the most distressing side effects of chemotherapy, with many women experiencing depression, shame, loss of confidence, and anxiety from alopecia, as well as the feeling of “standing out” and the distress from the probing questions that this altered appearance can draw.
The fear of hair loss and the associated distress has been reported to result in some patients refusing chemotherapy treatment to avoid developing alopecia (here and here).
Chemotherapy-induced alopecia also strongly influences how others perceive cancer patients, the visibility of disease, social relationships, and sexuality (here and here). In addition to the physical and psychosocial impact, chemotherapy-induced alopecia can also be financially detrimental due to expensive items, such as wigs and hair regrowth treatment.
Increasing access to scalp cooling technology
In 2020, Cancer Australia updated its guidelines for the management of early breast cancer to include scalp cooling in conjunction with chemotherapy to reduce the risk of hair loss in patients.
Despite these updated guidelines, access gaps continue to persist across the country, with patients in both metropolitan and regional areas of Australia often missing out on the ability to make an informed decision to use scalp cooling as part of their treatment. Barriers to accessing and implementing scalp cooling in Australia include adequate nursing staff, workload, capacity, changes in patient flow and cost. Furthermore, scalp cooling procedures are not currently funded under the Medicare Benefits Schedule (MBS), often resulting in the need for hospital and patient fundraising to provide patient access to scalp cooling technology.
We believe scalp cooling technology should be offered as part of standard of care in all medical oncology clinics across the private and public sectors for suitable patients.
History of scalp cooling
Since the 1970s, a variety of techniques have been proposed to prevent chemotherapy-induced alopecia, including scalp cooling, scalp compression with tourniquet, and various medications. Currently, scalp cooling technology that continuously circulates coolant into a cap is the most utilised device worldwide; and of the many interventions tried and studied, it has become well regarded as an effective and safe strategy, used in more than 30 countries (here and here).
The mechanism of action of scalp cooling can be explained in two ways:
- by vasoconstriction – decreased blood flow to the hair follicles during chemotherapy infusion interrupts the uptake of the cytotoxic agents in the hair follicles;
- by lessening biochemical activity – hair follicles with reduced biochemical activity are less likely to be damaged by chemotherapy agents.
Scalp cooling is carried out before, during and for some time after chemotherapy infusion (90–120 minutes). The success of scalp cooling may vary according to several factors, including chemotherapy regimen, dose, and schedule; infusion duration; drug metabolism; concomitant comorbidities; consistency with scalp cooling temperature due to scalp fitting; post-infusion cooling time; and the type of system used (here and here).
Recent advances in scalp cooling technology provide innovative methods of head wrapping to achieve better scalp fitting, thereby improving the consistency of temperature across the scalp.
Initially studied in early stage breast cancer, scalp cooling devices are now used in the treatment of patients with a broad range of solid tumours, including ovarian, colorectal and prostate cancer.
Efficacy of scalp cooling
Results of one prospective cohort study showed that of the 106 patients in the scalp cooling group receiving adjuvant or neoadjuvant chemotherapy regimens excluding sequential or combination anthracycline and taxane, included in the primary analysis, 67 (66.3%) demonstrated hair loss of 50% or less compared with 0 of 16 (0%) in the control group.
In a further randomised clinical trial of 182 women with breast cancer receiving chemotherapy with taxane, anthracycline or both, those who underwent scalp cooling were significantly more likely to have less than 50% hair loss compared with no scalp cooling (50.5% v 0%).
A systematic review and meta-analysis examining the efficacy of intervention for prevention of chemotherapy-induced alopecia showed scalp cooling was the most common preventive method and significantly reduced the development of chemotherapy-induced alopecia.
Why it’s important for patients to keep their hair: anecdotal insights
Scalp cooling technology has two benefits to cancer patients. The first advantage is the ability of patients to move freely in their social environments without automatically being recognised as a “cancer patient”. This gives the patient the control to inform and disclose their personal medical details to whom they choose and when, which in turn increases the patients’ control over their disease. For many cancer patients, the lack of control over their prognosis, advised treatments and complications is disempowering.
The other gain, particularly for breast cancer patients, is the ability to maintain some aspects of their physical appearance. For many breast cancer patients, the disease attacks many aspects of their femininity including, but not limited to, breast surgery, potential implications to fertility, potential surgery to the female reproductive system, new enforced menopausal status, body composition and sexual health. For many women, the ability to maintain the very visual feature of hair is key to maintaining their identity as an individual and as a woman.
Role of breast cancer nurses and integrated team in scalp cooling programs
Cancer nurses and medical oncologists have a critical role to play in ensuring the effective roll out of scalp cooling programs (here and here).
Patients who receive detailed educational materials on scalp cooling, as well as having training to assist them in using the device, have an increased chance of minimising alopecia and retaining their hair.
Typically, chemotherapy nurses fit the cap on a patient after switching on the cooler and monitor the patient during scalp cooling. The fitting of the cap is critical, as air between the cap and scalp skin increases the temperature, which can result in less successful outcomes.
Patients utilising the scalp cooling technology will also have to stay in clinic for a longer time, requiring oncologists to work closely with nursing and administration staff to ensure effective and streamlined rostering.
Medical oncology clinics investing in scalp cooling technologies for the first time must also ensure the right support network, training and resources are in place to ensure patients are comfortable with the technology and to maximise its efficacy.
Scalp cooling is a well tolerated option to prevent chemotherapy-induced alopecia and can help minimise some side effects of cancer treatment and have a potentially significant impact on patients’ health-related quality of life and psychosocial wellbeing. We hope to see continued improvements in access to supportive care services such as scalp cooling for Australian breast cancer patients and believe scalp cooling has a critical role to play in modern integrated cancer care pathways.
Dr Connie Diakos is a medical oncologist at GenesisCare St Leonards and Frenchs Forest, and is a Staff Specialist at Royal North Shore Hospital and Conjoint Senior Lecturer at the University of Sydney.
Dr Sally Baron-Hay is a medical oncologist at GenesisCare St Leonards and Frenchs Forest, and Royal North Shore Hospital, where she is also a supervisor and mentor for Advanced Medical Oncology Trainees through the Royal Australasian College of Physicians.
Dr Lina Pugliano is a medical oncologist specialising in exercise and cancer management based at GenesisCare in St Leonards and the Mater Hospital, North Sydney. She is also the Managing Director of Cancer Fit Australia.
Elaine Arnold is a McGrath breast cancer nurse with over 12 years’ experience in both the public and private sector.
Paula Mottlee is a clinical nurse specialist in oncology at GenesisCare St Leonards.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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