This study is the first to show that the PICT can be decreased to 20 minutes for patients treated with weekly paclitaxel (dosage of 70–90 mg/m2). No difference in the need to wear head covering was found between 45- and 20-minutes PICT. In addition, the results of a shorter PICT were comparable with the efficacy of the previous collected data from the Dutch Scalp Cooling Registry with a standard 90-minutes PICT. These clinical practise changing results were seen in both paclitaxel monotherapy, as well as in paclitaxel regimens combined with other chemotherapy or monoclonal antibodies.
In this study 78% of the patients felt they did not need head covering after being treated with weekly paclitaxel. Similar to previous trials, the number of patients that did not need head covering was high. Scalp cooling was well tolerated with high median VAS scores. Our results are in accordance with the results of the other scalp cooling studies with a shorter PICT in 3-weekly docetaxel-containing chemotherapy (12, 15) and results of scalp cooling in taxane-based chemotherapy (3, 6, 18). In the docetaxel PICT study 61% of the patients were male, whereas in our study predominantly female patients (95%) participated. In the study from Komen et al. 95% of the male patients was not wearing any head covering during the trial, in contrast to the female patients, where only 41% did not need head covering (12). There is a general assumption that men are less likely to wear a wig or other head covering and accept more hair loss. Nevertheless, in our study with mostly women, the results are still excellent and comparable.
Consistent improvement of patient’s QoL when using scalp cooling has not been reported so far (19).
There are several possible explanations for the lack of positive impact. Firstly, QoL assessments are generally covering a variety of domains like global health status, physical and emotional symptoms, reflecting little information on well-being specially associated with CIA. The CADS, used in this study will be more appropriate to assess the impact of CIA on QoL in patients who use scalp cooling. Secondly, patients who develop CIA despite can have worse QoL, when compared to patients who accept hair loss from early on and choose not to undergo scalp cooling (20). In our study we did observe significantly increasing CADS scores in patients with hair loss despite scalp cooling, consistent with this assumption. A recent study indicates that impact on body image and signs of depression are related to patients´ expectations of the efficacy of scalp cooling (21). Additional, coping with hair loss can negatively impact patients’ lives (22). Therefore, careful counselling and guidance, with setting of realistic expectations, for patients who choose scalp cooling is of importance. Increasingly, the incidence of permanent chemotherapy-induced alopecia (pCIA) after taxane chemotherapy is reported (23, 24). A phenomenon, especially seen after docetaxel treatment, however it has been described after paclitaxel treatment as well (24). Although pCIA is rare, this emphasizes the importance of offering scalp cooling when initiating taxane treatment, as it has shown to diminish the incidence of pCIA (24).
Spending 70 minutes less in the hospital during every administration of paclitaxel as a result of a shorter PICT is a great benefit for patients as some of them reject scalp cooling because of the time investment (25). Furthermore, it proved to be feasible for patients treated with taxanes. The advantage of an early discharge, which creates opportunities to treat more patients on one day, is desirable and cost-effective for hospitals. Future research should explore if a shorter PICT should be the standard for more types of chemotherapy.
In conclusion, this study showed retainment of very good results of scalp cooling in weekly paclitaxel-containing chemotherapy regimens, despite shortening the PICT. Based on this study, a 20 minutes PICT can be recommended as the new standard PICT for patients treated with weekly paclitaxel-containing schedules.