This is a randomized, double-blind, multi-center controlled trial which aims at exploring the efficacy of YH0618 granule on chemotherapy-induced hair loss in patients with breast cancer and elucidating the potential mechanism from the aspect of kidney deficiency or renal dysfunction. To achieve this goal, a total of 214 breast cancer patients who will receive first chemotherapy will be recruited for the study. The patients will be randomly divided into group A (YH0618 granule) and group B (placebo) using a 1:1 allocation ratio, adhering to the “CONSORT statement”  and “SPIRIT statement” . The primary outcome of this study is the time point of occurrence of hair loss reaching grade II assessed by WHO Toxicity Grading Scale, and objective indexes of hair quality and hair follicle recorded by a hair and scalp conditioners (CBS-603, CBS-Medical Skin Analysis, Taiwan). Secondary outcomes include changes of facial color and thumbnails color, grading of thumbnails ridging, assessment of quality life, fatigue, routine blood test, hepatic and renal function, and some medical indicators which can reflect kidney deficiency in Chinese Medicine. The flow chart of the study is shown in Figure 1 and Table 1. The recruitment, evaluation and data collection will be conducted at Galactophore Department of Guangdong Provincial Hospital of Chinese Medicine, Galactophore Department of The First Affiliated Hospital of Guangzhou University of Chinese Medicine, and Galactophore Department of The Third Hospital of Nanchang.
Ethical approvals have been confirmed from the institutional review board at Guangdong Provincial Hospital of Chinese Medicine (BF2018-100-01), The First Affiliated Hospital of Guangzhou University of Chinese Medicine (ZYYECK【2019】006) and The Third Hospital of Nanchang (2018-011). The trial was registered in the Chinese Clinical Trials Registry: ChiCTR1800020107. Patients will receive a detailed information sheet and complete written consent forms.
The trial is managed by the School of Chinese Medicine, HKU and data will be supervised by Data and Safety Monitoring Board (DSMB), which is an independent group of experts that advises funding agency and study investigators. DSMB members includes three experts from different fields (Western medical sciences, Chinese medicine and statistics). The DSMB is for quality control of this research data and make sure the integrity of the study. The protocol compliance, safety, and on-schedule study progress are also monitored by the DSMB. Auditing trial will be conducted every 3 months and the process will be independent from investigators. Study documents (soft- and hard-copies) will be retained in a secure location for 5 years after trial completion.
A total of 214 eligible patients will be recruited at different clinical centers. Inclusion criteria include: (1) females with stage I or II breast cancer aged between 18-75 years; (2) will receive first chemotherapy; (3) planning to receive chemotherapeutic agents containing taxanes or/and anthracyclines; (4) chemotherapy regimen will last at least 6 cycles with every three weeks a cycle; (5) adverse events assessed using WHO toxicity classification criteria< II grade; (6) a life expectancy is at least 6 months. Exclusion criteria are: (1) subjects with a medical history of hair transplantation; (2) suffer from psoriasis or severe scalp infection; (3) hair loss induced by alopecia areata, alopecia totalis or scalp injury, etc.; (4) pregnancy, lactation or potential pregnancy; (5) allergic to some specific food, like black soybean, etc.; (6) severe cardiac, hepatic, renal, pulmonary and hematic lesions or other diseases which will affect their survival; (7) who have any severe mental or behavioral disorders that cannot be fully informed; (8) be suspected or do have a history of alcohol and drug abuse; (9) cannot understand or fill in questionnaires because of cognitive disorders or low level of literacy; (10) a variety of factors affecting drug taking and absorption, such as inability to swallow, chronic diarrhea, intestinal obstruction, etc. Eligible patients will be invited to participate in this study after obtaining their written consent form. All participants will be closely monitored in the study.
Estimation of sample size
The primary outcome in this study is the time point of occurrence of chemotherapy-induced hair loss reaching grade II measured by WHO Toxicity Grading Scale for Determining the Severity of Adverse Events. Our previous results showed that YH0618 could cause the incidence of hair loss grade <II to reach 50% for patients who have completed chemotherapy, and the difference between the incidence of hair loss grade <II in YH0618 group and control group was 15%. Thus, the difference in proportion between the two groups will be measured by Z-test. To achieve a two-sided type I error alpha = 0.05 and power: (1-beta) = 80%, the minimal number of subject need in each group is 85. We estimated a 20% attrition rate at the end of follow-up; hence, a sample size of at least 107 in each group (214 in total) is planned for this study.
Randomization and blinding
Each subject will obtain an unique number after completing written consent. A computer blocked random number sequence with a block size of four will be generated centrally by a statistician not involving in this study. As YH0618 granule and placebo show the same appearance, a double-blind model will be adopted. Therefore, the randomization sequence and different groups will be kept hidden from subjects, practitioners, data collectors and statisticians.
Intervention and control condition
Prior to intervention, baseline data will be collected including demographics, medical characteristics, assessment of chemotherapy-induced hair loss, facial color, thumbnails color, grading of thumbnails ridging, quality of life, blood routine test, and hepatic and renal function. After that, subjects assigned to group A will receive YH0618 granules three times a day (6 g each time), 6 days a week, mixing with 300 ml warm water from the first to the fourth chemotherapy cycle. Subjects in group B will receive the placebo granule in the same manner. Then, all the subjects will be followed up until one month after chemotherapy. All specific methods, such as scalp cooling, used for reducing hair loss will be prohibited during the clinical trial. Both YH0618 granules and placebo are produced by Guangzhou Kanghe Pharmaceutical Co., Ltd., which meets national standards.
The primary outcome is the time point of occurrence of hair loss reaching grade II assessed by WHO Toxicity Grading Scale, and objective indexes of hair quality and hair follicle recorded by a hair and scalp detector (CBS-603, CBS, Taiwan) before the fifth chemotherapy.
Grading of chemotherapy-induced hair loss
WHO Toxicity Grading Scale is commonly used to monitor and rate severity of anticancer drugs-induced toxicity [19, 20]. The grading criteria for hair loss is shown in Table 2. Alopecia assessments will be conducted by a clinician blinded to treatment assignment, and by the participant.
Objective measurement of hair loss
In order to objectively evaluate the hair quality and hair follicle, a hair and scalp detector (CBS-603) will be used. The detector obtained patents in the United States, German, Japan, China, and China Taiwan, and many international authentication from Conformite Europeenne (CE), Federal Communications Commission (FCC), and Restriction of Hazardous Substances (RHoS). The detector is composed of 10X-200X Hair and Scalp Camera and software. The whole top of the head, a wide range of hair loss and the condition of hair follicles could be clearly filmed with 10X, 50X and 200X, respectively. The software has a function of testing through which hair test and analysis can be conducted. In this study, identification and classification of the level of hair loss, hair diameter and quality will be analyzed.
Secondary outcomes include changes of facial color and thumbnails color, grading of thumbnails ridging, assessment of quality life, fatigue, routine blood test, hepatic and renal function, and some medical indicators which can reflect kidney deficiency in Chinese Medicine.
Facial color and thumbnails color
The assessment of facial and thumbnails color is used by L*a*b system, which is the same as the clinical trial we conducted before . In the fixed surroundings, the skin color of the forehead, right and left cheeks, jaw, and the thumbnail color will be recorded by the hair and scalp detector with 50X.
Grading of thumbnails ridging
The grading of left and right thumbnail ridging will be measured by National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE). The definition of nail ridging is a disorder characterized by vertical or horizontal ridges on the nails. The grading criteria for nail ridging is shown in Table 3.
Quality of life measurement
Quality of life has been regarded as an important index to measure and monitor cancer patients’ treatment outcomes . Chinese version of the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B) with good reliability and validity will be used to measure breast cancer-specific quality of life . The tool includes 37 items scored on a 5-point Likert scale, ranging from 0 to 4 with higher scores indicating better quality of life [23, 24]. The items are classified into five subscales: Physical Well-Being, Social/Family Well-Being, Emotional Well-Being and Functional Well-Being, which constitute the FACT-General, and the additional concerns for breast cancer, which is called the Breast Cancer Subscale. A total score is calculated by summing all subscale scores.
Fatigue will be measured by the Chinese version of FACIT-Fatigue version 4, a 13-item FACIT Fatigue Scale, which could be used for patients of any tumor type . Each item scored on a 5-point Likert self-report scale, ranging from 0 to 4. A total score is obtained by summing all item scores and a high score indicates less fatigue.
Clinical objective examination
Routine blood test, and assessment of liver and kidney function are the same as our previous trial . Based on the evaluation standard of kidney deficiency in Chinese Medicine, kidney deficiency will be divided into deficiency of kidney qi, deficiency of kidney yang and deficiency of kidney yin. Modern studies also found that kidney deficiency syndrome has a modern pathophysiological basis, clinically manifested as changes in the relevant medical indicators such as the adrenal axis, thyroid axis, gonadal axis, renin-angiotensin, immune energy, liver and kidney function and hematopoietic function . So in this study, Immune indices including immunoglobulinM (IgM), alexin C3, Helper T cells CD4+, CD8+T cell and some metabolic index of microelement such as Mg, Cu, Zn, Fe.
All participants will be assessed within 3 days before every chemotherapy from the first to the fifth chemotherapy. Then, all the subjects will be followed up and the final assessment will be conducted at one month after the last chemotherapy. Professional research assistant will assign YH0618 granules or placebo, and notify the subjects of dosage and time. Quality and compliance to intervention will be achieved by checking attendance records and the diary of self-record kept by each participant.
Adverse events will be recorded through self-reports spontaneously by participants or asking the participants the open-ended question “How are you feeling?” via phone or face-to-face. Any questions concerning adverse events will be reported regardless of whether they were deemed to be related to the treatment be assessors and be sent to the Institutional Review Board of every clinical centers.
All analyses will be performed based on intention-to-treat principles, any missing data in the follow up visits will be imputed using multiple imputation. Descriptive analyses as means and standard deviations (SDs) will be used to describe the demographics and clinical characteristics of the participants. The primary efficacy analysis compared the hair loss grading between YH0618 granule and control before the fifth chemotherapy using Fisher exact test. The changes of hair diameter between the two groups after 4 cycles of chemotherapy will be compared by independent samples t-test. A multivariable logistic regression model will be used to explore the treatment effect. Potential confounding variables will be identified as those that differ among treatment groups at baseline and are significantly associated with outcomes. Changes from baseline to the final assessment in quality of life assessed by the FACT-B and objective indicators in blood will be compared using Wilcoxon rank sum tests. Unless otherwise specified, 2-sided statistical tests will be used and the significance level will be set at p < 0.05.
In this trial, an interim analysis will be performed when approximately two-thirds of the planned observations are enrolled. The results are analyzed by the statistician and only DSMB members have access to the results to test for futility, safety and efficacy of the trial. If there are no any statistically significant differences in the primary outcomes for the interim analysis, the study may be terminated.