Considerations for the Use of Scalp Cooling Devices in Black Patients

To the Editor:

Scalp cooling, recently included in the National Comprehensive Cancer Network (NCCN) guidelines for prevention of chemotherapy-induced alopecia (CIA) in patients with breast cancer, works by reducing chemotherapy delivery to the hair follicle by enhancing vasoconstriction. The cooler temperature also promotes reduced metabolism of the chemotherapeutic agent within the hair follicle.^1,2 Although there is no standard preparation protocol for scalp cooling, patients are typically asked to wet the hair or apply conditioner before wearing the cap to improve conductivity and reduce the pretreatment cooling time.³ In addition, proper cap fitting and contact with the scalp is recommended to help prevent CIA.⁴ Considering the importance of scalp fit to treatment efficacy, we call attention to the following clinical scenario: A 43-year-old Black woman diagnosed with estrogen receptor–positive and human epidermal growth factor receptor 2 (HER2)–negative breast cancer is scheduled for chemotherapy treatment with docetaxel and cyclophosphamide. She is offered scalp cooling to prevent CIA. The device kit contains a cooling cap, shampoos and conditioner, along with instructions for preparation. She notes that the pretreatment instructions for how to care for her hair are different from her typical haircare practice. She is specifically concerned that the instructions to wet the hair for improved conduction would cause her hair to become too curly and too bulky and would prevent the cooling cap from fitting tightly. She considers braiding or heat or chemically straightening her hair as well as using hair extensions to optimize the effectiveness of the scalp cooling device. She asks for guidance from a physician.

The scenario above highlights a need for physicians to better understand Black kinky or curly hair, its properties, and how styling it is different from styling straight hair. Although straight hair and curly hair have identical chemical properties, the difference in physical properties such as shape, texture, and density may necessitate further considerations in the instructions for preparing hair before using scalp cooling devices. Although differences in hair texture and shape may seem to be trivial, the effectiveness of scalp cooling may be affected by factors determined by the hair type. Areas of the scalp with inadequate cap-scalp contact are not protected from CIA.⁴ In addition, computer modeling of scalp cooling correlated hair thickness with decreased effectiveness of the cooling effect of the cap.² Unlike the straight hair of people of White or Asian race/ethnicity that lays flat when it is wet, curly hair tends to become bulkier when it gets wet. In addition, although both straight and curly hair may be altered by using heat and chemicals, physical properties of curly hair are often altered to a much greater extent, which causes a variation among women with kinky or curly hair.⁵ Depending on the method used, the hair might assume a shape or form that varies under different conditions. For instance, when curly hair is straightened using heat, it appears flat and straight when dry, but returns to its original bulky and curly state as soon as it is dampened. By contrast, kinky or curly hair which has been straightened using chemicals such as those in a permanent wave or hair relaxers remains straight regardless of being dry or wet.⁵

Furthermore, Black women with tightly curled hair more often wear hairstyles such as braids and weaves that involve the use of hair extensions to protect their hair from damage associated with daily grooming.⁵ Because oncology physicians and nurses care for patients of diverse ethnicities, basic knowledge of the various hair types and styles is necessary to provide Black patients with relevant counseling and realistic expectations of difficulties they might encounter. To enhance the likelihood of treatment success, we have three suggestions: First, Black patients, regardless of hair type, should be encouraged to remove all hair extensions. Second, those with natural hair without chemical straightening may be advised to avoid excess wetting of the hair and instead thermally straighten the hair and apply an emollient or grease to the ends of the hair before wetting the scalp before treatment. Small single twists or braids of natural hair without extensions are permissible. Third, patients with chemically straightened hair may wet the hair before treatment.

Additional recommendations are summarized in Table 1. We urge further research on the optimal visit protocol for use of scalp cooling devices in Black patients to prevent them from missing the potential benefit of this new technology.

TABLE 1.

Suggestions for Black Patients With Tightly Curled Hair Undergoing Scalp Cooling

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Considerations for the Use of Scalp Cooling Devices in Black Patients

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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Vered Stearns

Research Funding: AbbVie, Pfizer, MedImmune, Novartis, Puma Biotechnology, Biocept

Other Relationship: Immunomedics

Crystal Aguh

Consulting or Advisory Role: L’Oreal, LEO Pharma

Other Relationship: UpToDate

No other potential conflicts of interest were reported.