Supportive Care in Cancer

, Volume 27, Issue 5, pp 1919–1925 | Cite as

Prolonging the duration of post-infusion scalp cooling in the prevention of anthracycline-induced alopecia: a randomised trial in patients with breast cancer treated with adjuvant chemotherapy

  • Manon M. C. KomenEmail author
  • Corina J. G. van den Hurk
  • Johan W. R. Nortier
  • Tjeerd van der Ploeg
  • P. Nieboer
  • Jacobus J. M. van der Hoeven
  • Carolien H. Smorenburg
Original Article



Scalp cooling as a method to reduce the incidence of chemotherapy-induced alopecia (CIA) is increasingly used in daily practice worldwide. However, in patients treated with 5-fluorouracil, epirubicin and cyclophosphamide (FEC), scalp cooling fails in 48–67% of patients. This study investigated the efficacy of extended duration of post-infusion scalp cooling in breast cancer patients treated with this regimen.


In this prospective multi-centre randomised study, 102 patients with early breast cancer treated with adjuvant FEC chemotherapy were randomly assigned in a 1:1 ratio to a post-infusion cooling time of 90 or 150 min. The primary endpoint was the need to wear a wig or other head covering to mask visible hair loss.


Sixteen out of 48 patients (33%) treated with 90 min of post-infusion cooling did not need any head covering, compared with 21 out of 46 patients (45%) treated with 150 min of post-infusion cooling (p = 0.2). WHO grades 2–3 (moderate-complete) alopecia were reported more often in patients treated with 90-min post-infusion cooling time (n = 25/51 (49%) versus n = 17/51 (33%); p = 0,02). Scalp cooling was well-tolerated (mean Visual Analogue Score 7.4) and only three patients (3%) stopped due to intolerance during treatment.


Extending the duration of 90-min post-infusion scalp cooling to 150 min in patients treated with adjuvant FEC chemotherapy was well-tolerated but did not significantly diminish the need for head covering. However, grades 2–3 alopecia was seen less often with prolonged post-infusion scalp cooling.


Chemotherapy FEC Scalp cooling Alopecia Hair loss Breast cancer 



The authors thank all the patients who participated in our study. Furthermore, we thank all the investigators of the participating hospitals: Dr. Valster, Lievensberg Ziekenhuis, Dr. Van Groeningen, Amstelland ziekenhuis, Dr. de Klerk, Waterlandziekenhuis, Dr. Pruijt, and Jeroen Bosch Ziekenhuis.

Compliance with ethical standards

Procedures performed in this study were in accordance with the 1964 Helsinki Declaration and its later amendments and in accordance with the ethical standards of the institutional review board and independent ethics committee. All participants gave written informed consent prior to enrolment and randomisation.

Conflict of interest

The authors declare that they have no conflict of interest.

The authors have full control of all primary data and agree to allow the journal to review their data if requested.


  1. 1.
    Lemieux J, Maunsell E, Provencher L (2008) Chemotherapy-induced alopecia and effects on quality of life among women with breast cancer: a literature review. Psychooncology 17:317–328CrossRefGoogle Scholar
  2. 2.
    Mols F, van den Hurk CJ, Vingerhoets AJ, Breed WP (2009) Scalp cooling to prevent chemotherapy-induced hair loss: practical and clinical considerations. Support Care Cancer 17:181–189CrossRefGoogle Scholar
  3. 3.
    Rosman S (2004) Cancer and stigma: experience of patients with chemotherapy-induced alopecia. Patient Educ Couns 52:333–339CrossRefGoogle Scholar
  4. 4.
    van den Hurk CJ, Mols F, Vingerhoets AJ, Breed WP (2010) Impact of alopecia and scalp cooling on the well-being of breast cancer patients. Psychooncology 19:701–709CrossRefGoogle Scholar
  5. 5.
    Breed W, van den Hurk CJ, Peerbooms M (2011) Presentation, impact and prevention of chemotherapy induced hair loss: scalp cooling potentials and limitations. Dermatology 6:109–125Google Scholar
  6. 6.
    Nangia J, Wang T, Osborne C, Niravath P, Otte K, Papish S, Holmes F, Abraham J, Lacouture M, Courtright J, Paxman R, Rude M, Hilsenbeck S, Osborne CK, Rimawi M (2017) Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: the SCALP randomized clinical trial. JAMA 317:596–605. [doi].
  7. 7.
    Ross M, Fischer-Cartlidge E (2017) Scalp cooling: a literature review of efficacy, safety, and tolerability for chemotherapy-induced alopecia. Clin J Oncol Nurs 21:226–233. [doi].
  8. 8.
    Bulow J, Friberg L, Gaardsting O, Hansen M (1985) Frontal subcutaneous blood flow, and epi- and subcutaneous temperatures during scalp cooling in normal man. Scand J Clin Lab Invest 45:505–508CrossRefGoogle Scholar
  9. 9.
    Grevelman EG, Breed WP (2005) Prevention of chemotherapy-induced hair loss by scalp cooling. Ann Oncol 16:352–358CrossRefGoogle Scholar
  10. 10.
    Komen MM, Smorenburg CH, van den Hurk CJ, Nortier JW (2013) Factors influencing the effectiveness of scalp cooling in the prevention of chemotherapy-induced alopecia. Oncologist, 18, 885, 891Google Scholar
  11. 11.
    Lemenager M, Lecomte S, Bonneterre ME, Bessa E, Dauba J, Bonneterre J (1997) Effectiveness of cold cap in the prevention of docetaxel-induced alopecia. Eur J Cancer 33:297–300CrossRefGoogle Scholar
  12. 12.
    Komen MM, Smorenburg CH, Nortier JW, van der Ploeg T, van den Hurk CJ, van der Hoeven JJ (2016) Results of scalp cooling during anthracycline containing chemotherapy depend on scalp skin temperature. Breast 30:105–110.Google Scholar
  13. 13.
    van den Hurk CJ, Peerbooms M, van de Poll-Franse LV, Nortier JW, Coebergh JW, Breed WP (2012) Scalp cooling for hair preservation and associated characteristics in 1411 chemotherapy patients - results of the Dutch Scalp Cooling Registry. Acta Oncol 51:497–504Google Scholar
  14. 14.
    Coukell AJ, Faulds D (1997) Epirubicin. An updated review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in the management of breast cancer. Drugs 53:453–482CrossRefGoogle Scholar
  15. 15.
    Danesi R, Fogli S, Gennari A, Conte P, Del Tacca M (2002) Pharmacokinetic-pharmacodynamic relationships of the anthracycline anticancer drugs. Clin Pharmacokinet 41:431–444CrossRefGoogle Scholar
  16. 16.
    Massey CS (2004) A multicentre study to determine the efficacy and patient acceptability of the Paxman scalp cooler to prevent hair loss in patients receiving chemotherapy. Eur J Oncol Nurs 8:121–130CrossRefGoogle Scholar
  17. 17.
    World Health Organisation (1979) Handbook for reporting results of cancer treatment. WHO offset publGoogle Scholar
  18. 18.
    Dupont WD, Plummer WD (2005) Power and Sample Size CalculationGoogle Scholar
  19. 19.
    Cohen B (2008) The cross-section trichometer: a new device for measuring hair quantity, hair loss, and hair growth. Dermatol Surg 34:900–910Google Scholar
  20. 20.
    Brenner DE (1987) Approaches to the problem of individual doxorubicin dosing schedules. Pathol Biol (Paris) 35:31–39Google Scholar
  21. 21.
    Robert J, Illiadis A, Hoerni B, Cano JP, Durand M, Lagarde C (1982) Pharmacokinetics of adriamycin in patients with breast cancer: correlation between pharmacokinetic parameters and clinical short-term response. Eur J Cancer Clin Oncol 18:739–745CrossRefGoogle Scholar
  22. 22.
    Eksborg S, Hardell L, Bengtsson NO, Sjodin M, Elfsson B (1992) Epirubicin as a single agent therapy for the treatment of breast cancer--a pharmacokinetic and clinical study. Med Oncol Tumor Pharmacother 9:75–80Google Scholar
  23. 23.
    van den Hurk CJ, Breed WP, Nortier JW (2012) Short post-infusion scalp cooling time in the prevention of docetaxel-induced alopecia. Support Care CancerGoogle Scholar
  24. 24.
    Komen MM, Breed WP, Smorenburg CH, van der PT, Goey SH, van der Hoeven JJ, Nortier JW, van den Hurk CJ (2016) Results of 20- versus 45-min post-infusion scalp cooling time in the prevention of docetaxel-induced alopecia. Support Care Cancer 24:2735–2741CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Manon M. C. Komen
    • 1
    Email author
  • Corina J. G. van den Hurk
    • 2
  • Johan W. R. Nortier
    • 3
  • Tjeerd van der Ploeg
    • 4
  • P. Nieboer
    • 5
  • Jacobus J. M. van der Hoeven
    • 6
  • Carolien H. Smorenburg
    • 7
  1. 1.Department of Internal Medicine and Medical OncologyMedical Centre AlkmaarAlkmaarThe Netherlands
  2. 2.Comprehensive Cancer Organisation the NetherlandsUtrechtThe Netherlands
  3. 3.Department of Medical OncologyLeiden University Medical CentreLeidenThe Netherlands
  4. 4.Business, Finance and Law departmentInholland AlkmaarAlkmaarThe Netherlands
  5. 5.Department of Medical OncologyWilhelmina Ziekenhuis Assen, Europaweg-Zuid 1AssenThe Netherlands
  6. 6.Department of Medical OncologyRadboud University Medical CentreNijmegenThe Netherlands
  7. 7.Department of Medical OncologyAntoni van Leeuwenhoek, Plesmanlaan 121AmsterdamThe Netherlands

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