Oncologists Reluctant to Initiate Discussions with Patients About Scalp Cooling Therapy for Chemotherapy-related Hair Loss

By Teresa Hagan Thomas

Scalp cooling therapy is one of the few evidence-based treatments available to treat chemotherapy-induced alopecia (hair loss),  yet only 26% of US oncologists introduce the topic into conversations with patients, according to the results of a national survey published in the JCO® Oncology Practice. Financial concerns for the patient and concerns about efficacy are the most frequent reasons given for not discussing scalp cooling therapy with patients, researchers from the University of Michigan, Ann Arbor, report.

The incidence of chemotherapy-related alopecia is estimated to be around 65%, while its prevalence varies according to the type and schedule of the drugs used. Although often anticipated, alopecia is a significant negative impact on patients’ body image, self-esteem, intimacy, and quality of life, so much so that around 8% of patients refuse chemotherapy in order to avoid hair loss.

Common ways in which oncology nurses and other health care providers provide support for patients experiencing hair loss are through prosthetics (e.g., wigs), topical ointments (e.g., minoxidil)), and self-management strategies. Over the past several years, scalp cooling therapy has become recognized as a safe and moderately effective way of preventing hair loss. Access, however, remains a major barrier.

Scalp cooling therapy consists of a tight-fitting cap worn before, during, and after chemotherapy infusion. The cap is filled with a chilled liquid flowing through it. The cap constricts blood vessels in the head, decreasing the flow of the chemotherapy to the hair growing cells on the scalp. Some cancer clinics have their own scalp cooling therapy equipment, and some patients purchase their own caps and bring them to their treatment sessions.

For the national survey, the largest and most comprehensive of its kind to date, medical student Madison Novice and colleagues devised a 33-question survey that was distributed to 600 providers from the American Society of Clinical Oncology (ASCO) research survey pool. The questions focused on demographics, facility scalp cooling therapy availability, and provider knowledge, attitudes, and perceptions of and practice patterns with scalp cooling therapy. Out of 155 (25.8%) responses, most (118) came from medical oncologists, most often treating breast cancer.

Among the respondents to the survey, 55% recognized the effects of hair loss as a major concern for their patients, and 53% reported being very familiar with scalp cooling therapy. While 67% believed that all patients should be offered the service, only 36% maintained that the effort and cost of scalp cooling therapy were worth the benefit. Only 26% of providers said they initiated conversations about scalp cooling therapy always or most of the time.

The most frequently cited barriers to discussing scalp cooling therapy were patient finances (58%) and efficacy of the treatment (31%). Safety concerns were rarely a barrier. Responders were more likely  to initiate a conversation about the therapy if hair loss appeared to be a major concern for their patient.

The researchers concluded that providers who were more familiar with scalp cooling therapy were more likely to initiate conversations with patients and support its use. They suggested that with efforts to increase awareness, familiarity could increase provider willingness to provide scalp cooling therapies. They also suggested targeting modifiable factors that impact the efficacy of effective scalp cooling therapies.

Overall, this study highlights areas for improvement in provider knowledge and attitudes regarding scalp cooling therapy. The results “suggest the need for physician education and exposure to scalp cooling therapy, through either physician-directed learning or short training programs, and clear institutional guidelines for the use of scalp cooling therapy,” the researchers say. They also recognize that scalp cooling therapy is not usually covered by medical insurance, “so patients must pay out-of-pocket or seek philanthropic support.” They call for new long-term support options to facilitate widespread adoption.

Oncology nurses seeking to support patients concerned about hair loss can work to improve awareness about this therapy and contribute to the evidence-based practice scholarship documenting its efficacy and safety.