Follow the Evidence When Using Scalp Cooling for Cancer Alopecia

September 09, 2021

Scalp cooling, also known as cryotherapy, may reduce the risk of chemotherapy-induced alopecia (CIA) in patients with cancer, but how do you know if the therapy is right for your patients? According to speakers at an ONS BridgeTM virtual conference session on September 9, 2021, start with the evidence.

In 2020, ONS made two recommendations regarding alopecia for its guidelines on skin toxicities ( As with all ONS Guidelines™, a multidisciplinary team bases recommendations on a systematic review of evidence. The team also weighed the benefits and harms and considered the cost, patient preferences, feasibility, acceptability, and equity.

Speaker George Ebanks, BSN, RN, OCN®, emphasized that not all guidelines were created with the same rigor as ONS’s, so nurses must pay attention to how guidelines are developed. But trusted guidelines like ONS’s provide a roadmap to best nursing practices.

“There is so much research evidence being generated—if nurses all had to review and synthesize it on our own, we would never have time to implement that evidence into practice,” Ebanks said.

The guidelines state that (, among patients with cancer who are receiving cytotoxic agents associated with CIA and are concerned about hair loss, scalp cooling may minimize or reduce alopecia severity and, additionally, topical minoxidil is better than no treatment for shortening or minimizing alopecia. Specifically, scalp cooling was found ( to reduce the risk of CIA by almost 50%, compared to not doing anything; 31% of patients reported that ( scalp cooling was associated with improvements in quality of life, while 62% found nonsignificant or no improvement.

Scalp cooling works by vasoconstriction, which minimizes the amount of chemotherapy reaching the hair follicles. It can be administered by a cooling system or cold cap 30–45 minutes before, during, and 20–90 minutes after chemotherapy infusions.

The ONS Guidelines panel found that not all patients tolerate scalp cooling; rates of discontinuation ranged from ( 3%–40%. Common adverse events included cold intolerance, headaches, and scalp discomfort. The panel also discussed access disparities and inequalities for scalp cooling. Related costs may pose financial barriers for some. 

Erica Fischer-Cartlidge, DNP, CNS, CBCN®, AOCNS®, EBP(CH), interim director of evidence-based nursing practice at Memorial Sloan Kettering Cancer Center (MSK), shared her center’s experience with implementing a scalp cooling program.

“There is pretty robust evidence that patients who cool are more satisfied with their hair preservation than those who don’t,” Fischer-Cartlidge said.

The team at MSK evaluated available vendors for the size and availability of machines, as ease of use, and financial considerations such as renting versus owning, patient billing, and overall patient cost because of insurance coverage variability. They also dedicated time to developing patient education materials.

Some of the additional factors the team considered, Fischer-Cartlidge said, were ensuring that the physical environment was ready, including power outlets, appropriate chairs, biomedical safety reviews, storage, and training. The infection control team established appropriate disinfection processes for the machines and shared caps between use.

Fischer-Cartlidge said they learned many lessons, but most notable was the need for interprofessional collaboration. Physician buy-in and the ability to project patient interest and volume were key.

Mary Heery, AOCNS®, CBCN, APRN, is a breast health specialist at the Smilow Family Breast Health Center at Norwalk Hospital Whittingham Cancer Center, Nuvance Health, a community cancer center. Like Fischer-Cartlidge, Heery said that implementing the program at her center involved many components, such as coordinating patient visits, staffing, planning for equipment upkeep, providing patient education materials, and obtaining consent and payment. A key aspect was educating physicians and mid-level providers on when to pitch the program to patients and how to refer them for treatment. This institution also sought community grant funding to help offset costs.

Heery reported ( a success rate of 84%–88% of patients maintaining more than 50% of their hair (Heery, Cohen & Mena, 2019).

“With patient commitment, well-developed patient education guidelines, and support from the healthcare team, incorporating cold cap devices into chemotherapy treatment regimens can improve scalp cooling therapy outcomes for patients,” Heery said.

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