Cold Caps May Reduce Hair Loss from Chemotherapy

Cold caps or scalp cooling is a process designed to help some women lose less hair during chemotherapy. Let us note at the start at this does not work for all chemo drugs, and that the results can be variable. Let us also add some history. Perhaps twenty years ago, there was briefly a lot of hype about cold caps to preserve hair during chemotherapy. The theory, then and now, is that the cold constricts blood vessels that run to the scalp and reduces or stops chemo drugs from going there. These earlier products were only briefly on the market; they turned out to be very uncomfortable, not to work very well, and some oncologists expressed concerns about limiting the blood flow to the scalp.

Several studies have found that 59-68% of women treated with taxanes lost less than half their hair if they used a cooling system.

Perhaps six years ago, improved cold caps came to the market. They are used primarily for women receiving chemotherapy for breast cancer, and only for some women based on the specific drugs being used. There has, again, been some expressed concern that scalp cooling may prevent chemo drugs from reaching the scalp. Since cancer cells can spread virtually anywhere, this is a legitimate worry, but it is noted that breast cancer very rarely spreads to the scalp. Multiple studies have compared outcomes for women who used scalp cooling techniques to those who did not and found no difference in the numbers of scalp metastases. This is, however, something to discuss with your doctor.

The FDA has approved two systems for use in the US: the DigniCap Scalp Cooling System and the Paxman System. Not all hospitals or treatment centers have these easily available. The benefit and success of scalp cooling in reducing hair loss depends on several things, most importantly the drugs used and the dose. Chemo drugs often used to treat breast cancer include anthracyclines (Adriamycin and Ellence) and taxanes (Taxol, Taxotere, and Abraxane). Women who do not receive an anthracycline have had better results with the cooling systems. Several studies have found that 59-68% of women treated with taxanes lost less than half their hair if they used a cooling system. I have known women who lost very little of their hair, so little that it was not noticeable to others, and I have known women who lost all their hair in spite of cooling caps.

Since, like everything else in Cancer World, there are no guarantees about saving your hair, this can become a tough decision. Remember that it is not irrevocable. If you start out chemo using a cap and decide you don’t like it, you can stop. A switch in the other direction is less useful because the damage has already been done.

Why, you might be wondering, wouldn’t you want to at least give this a try? Hair loss is usually the most dreaded side effect of chemo, and this seems a way to try to manage it. For many women it is. In fact, a study from Ireland found that women who used cold caps, whether or not they were successful, were happy with their decision. The possible reasons not to try this include cost, logistics, and discomfort; this assumes that you have talked with your doctor and there are no other medical reasons that make it an unwise choice.

What is the difference between the two systems, cold caps and scalp cooling? Cold caps look rather like old fashioned bathing caps. They must be kept in a cooler with dry ice or in a special biomedical freezer. Each cap warms up and thaws pretty quickly, so you need to replace it approximately every half hour. Scalp cooling systems use a single cap that is attached to a small machine. The machine circulates cold air through the cap for the duration of the chemo session; the cap does not need to be changed.

The cost depends on the system, the numbers of treatments, and the total length of time you need the caps. Most insurance companies do not (yet) cover this expense. The typical cost is $380-$450/month plus shipping charges. Some cancer centers also add a fee for their use as more time is required per treatment. It is worth contacting the manufacturer to ask about financial assistance, and it is also worth asking at your treatment facility. At BIDMC, ask to speak with the Community Resource Specialist (CRS) in the Oncology Social Work Group. The Rapunzel Project is a national organization that can help with this expense.

Let’s think about logistics. The primary issues are time required and assistance needed. To be effective, you have to wear the cap for an hour or so before the chemo begins and another hour or so after it finishes. Some women do not want to spend another two or more hours in the chemo chair. It is usually necessary to have someone to help with the process, and the infusion nurses may not have the time to do so. During the pandemic, this was especially problematic as most treatment centers did not allow patients to bring a companion. Most of the restrictions have eased a bit, so this part may be more manageable.

The discomfort means how you feel while you are wearing/using the cap. You almost certainly will be cold and have a headache. Some women also experience shoulder or neck pain, dizziness, or nausea. Dress in layers so that you can add or subtract a sweater or shawl over the time of treatment.

There is no doubt that it is better, always, to have options and some control. Considering using a scalp cooling system is one way to exercise your choices.