CLINICAL ONCOLOGY
Chemotherapyinduced hair loss
Acknowledgments This study was funded, as part of the Nursing Research Unit’s core programme of research, by the Chief Scientist Office of the Scottish Home and Health Department. The views and conclusions expressed are those of the authors and do not necessarily reflect those of the funding body. We acknowledge the assistance and co-operation of all those who supported us in this work, including JAl Health Care who provided equipment for scalp cooling.
Alison Tierney, a nurse researcher, and Jean Taylor, sister ofa specialist unit for the treatment of breast cancer, worked together on a study ofpatients undergoing chemotherapy. Here they describe some of the findings obtained about chemotherapy-induced hair loss and how these have helped nursing staff to be more confident about helping patients with this distressing side-effect of treatment.
Chemotherapy is an increasingly common treatment for many forms of cancer and, for some, it has proved enormously successful. However, this success has been tempered by the unpleasantness of its side-effects. Of all these, hair loss is often the most distressing. The temporary loss of hair may seem a relatively small cost for patients to pay for potentially life-saving treatment, but it can be emotionally devastating. Vicky ClementJones, a young doctor who died of ovarian cancer, said: 'Mentally 1 had prepared myself for the likelihood of losing my hair and having to wear a wig; but the physical reality of the hair falling out posed emotional and practical problems which I had not anticipated. Intell
ectually I knew what was happening, but emotionally it reinforced my feelings that I was losing part of myself (1). It is not difficult to imagine how intense these feelings may be for a woman with breast cancer who, in addition to hair loss, also has to cope with or face the possibility of the loss of a breast through surgery. Although nursing staff in the breast unit where this research was undertaken two-anda-half years ago were well aware of the distress that chemotherapy-induced hair loss can cause, they were uncertain of how best to prepare and help patients to come to terms with it. There were also doubts about whether the unit was making enough and proper use of scalp cooling, a procedure which can prevent hair loss from occurring. Nursing staff now have a more informed and confident approach in coping with the problem of chemotherapy-induced hair loss. Our research in the breast unit, with the co-operation of the patients and staff, has greatly contributed to this. An in-depth, prospective study of 60 chemotherapy JOHN BEHETS
Alison Tierney BSc (Soc Sc/Nurs), Phi), RGN, is Director, Nursing Research Unit, University of Edinburgh. Jean Taylor RGN, is Ward Sister, Breast Unit, Longniore Hospital, Edinburgh.
Scalp cooling pack being prepared.
< A mff x a ■
■
June 12/Volume 5/Number 38 1991 Nursing Standard 29
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CLINICAL ONCOLOGY
m
/
j
JOBS BRUITS
-
Scalp cooling pack being applied.
patients was made on an informed and volun tary basis. They were closely monitored from beginning to end of treatment and in follow up, and their experience and the side-effects were documented. Interest was not confined to the problem of hair loss, although that was investigated in particular detail and is the focus of this article. Readers who are inter ested in the study as a whole, and/or its method and procedures, are referred to the original research report (2). On the subject of hair loss, we collected an enormous amount of data. Once analysed, some of the findings were unsurprising, some provided thought-provoking insights and others suggested obvious ways in which the preparation and support of patients might be improved. We were not surprised to find that for many women hair loss was a particularly upsetting prospect. In pre-treatment interviews, just over a third of the patients admitted to feeling worried and/or upset about hair loss. One patient said: ‘Yes, it worries me because it would be an outward sign of my incapacity and that is upsetting when one is trying to be normal, even with cancer.’ Another confessed: ‘It's interesting because I didn’t expect it would really worry me, but it does . . . terribly. It seems so vain to think like that and 1 don’t know why I’m so bothered about it, but I am.’ A few confessed to having been so distressed about the prospect of hair loss that they had considered refusing chemotherapy. One said: ‘I was heartbroken about it. It really upset me,
to the point of wondering whether I could accept chemotherapy. I couldn't think how I’d cope with it. For me, the possiblity of losing my hair is much, much worse than losing a breast.’ Other patients had obviously worked through such feelings and realised that they could, or at least would, cope with hair loss. There were a number of women who were not concerned about hair loss. One said ‘I’m not worried. It just doesn’t seem important to me.’ There was actually one patient who welcomed the prospect of losing the hair she had never liked!
Individual concerns Although we were not surprised to uncover a great deal of distress about the prospect of hair loss, we soon realised that this should not automatically be assumed, and that the only way to assess individual patients’ concerns is to ask them. Getting patients to talk about their fears and describe their difficulties in coping with hair loss is also therapeutic, and we were informed of a number of practical methods of coping with the difficulties arising from hair loss and the need to wear a wig. Hair falling onto and adhering to clothes, bedclothes and food is a nuisance. One patient found that wearing rubber gloves was an effective way of removing hair from her clothes and pillow-case. Another wore a hairnet at night to avoid covering her pillow case with hair. Many complained that their
30 Nursing .Standard June 12/Volume 5/Number 38 1991 Downloaded from RCNi.com by ${individualUser.displayName} on Oct 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
CLINICAL ONCOLOGY
References 1. Clement-Jones V. Cancer and beyond: The formation of BAG UP. British Medical Journal. 1985. 291, 1021-1023. 2. Tierney A J et al. A Study to Inform Nursing Support of Patients Coping with Chemotherapy for Breast Cancer. Fdinburgh, Nursing Research Unit, Department of Nursing Studies, University of Kdinburgh. 1989. 3. Tierney A J. Preventing chemotherapy-induced alopecia in cancer patients: Is scalp cooling worthwhile? Journal of Advanced Nursing. 1987. 12, 303-310. 4. Hunt J M et al. Scalp hypothermia to prevent adriamycin-induced hair loss. Cancer Nursing. 1982. 5, 25-31. 5. Middleton J et al. Failure of scalp cooling to prevent hair loss when cyclophosphamide is added to doxorubicin and vincristine. Cancer Treatment Reports. 1985. 69, 373-375. 6. Parker R. The effectiveness of scalp hypothermia in preventing cyclophosphamide-induced alopecia. Oncology Nursing Forum. 1987. 14, 6, 49-53.
wig was either too hot or too cold, depending on the weather. Some found that wearing a scarf or hat added warmth. The insertion of a cotton lining reduced perspiration in summer and helped prevent the itchiness which many patients found particularly irksome. Restrictions on activity were another diffi culty, especially for a patient whose life centred on outdoor bowling and others who liked swimming regularly. Washing and styling was a practical difficulty and caused anxiety. One patient said: ‘I was terrified to wash the wig because I had to keep it wearable all the time for work. 1 washed it for the first time last weekend and was really anxious in case it fell apart. It didn’t do that but it did take ages to dry.' In the recommendations of the research report we suggested that consideration should be given to the provision of a second wig for patients, and that they should be offered advice and practical instruction on washing and styling. It is not so easy to suggest specific methods to alleviate the emotional problems many women encounter with hair loss and in having to wear a wig. Being encouraged to talk about these and knowing that there is a sympathetic ear seems to help. When hair loss was severe and sudden, as opposed to gradual thinning, most patients found the experience traumatic. One said: 'It was dreadful when it happened. It started so suddenly and just fell out in handfuls, and I was bald within a couple of days. 1 was absolutely shattered. 1 hadn’t expected it to be so awful.’ Once over the worst, many seemed to come to terms with the loss of their hair remarkably quickly and soon became accustomed to their wigs. For a few, however, the misery lasted longer. One patient said: ‘I'm managing, and managing the wig, which everyone says looks nice, but no-one knows the private agony.' We would all like to spare patients the experience of chemotherapy-induced hair loss. In pursuit of this goal, scalp cooling was introduced into the breast unit some years ago. Its use was spasmodic, however, because enthusiasm lapsed whenever it did not seem to be working. For the research study period, it was decided that a concerted effort would be made to use scalp cooling routinely and to monitor the outcome consistently. In prepara tion, all available literature on scalp cooling was reviewed (3) and guidance was sought from nurses at The Royal Marsden Hospital, where important original work on this has been carried out (4). Although all but three of the 60 patients elected to begin with scalp cooling, almost
half discontinued after one application. In almost all these cases hair loss had occurred, or was starting, by the time the second chemo therapy was due. The chemotherapy con cerned in all of these cases was CHOP (IV adriamycin 50mg/m2 in combination with cyclophosphamide lgm/m2 and vincristine 1.4mg/m2, supplemented by oral predniso lone 40mg for 5 days). CHOP was adminis tered to 32 patients and, by the end of treatment, 27 of these had total hair loss and three had severe hair loss, also requiring a wig. Although we did not use a controlled trial, our conclusion that scalp cooling is not effective in preventing CHOP-induced hair loss concurs with evidence from other reported studies (5).
No effect In contrast, mild hair loss, if any, was experienced by patients in the research sample who were receiving the other main chemo therapy regime employed, CMF (IV cyclo phosphamide 600-75()mg/m2, methotrexate 50mg/nV and 5-fluourouracil 600mg/m2). Of the 21 patients in the sample who were treated with CMF, five had no loss of hair and 15 only had mild hair loss. In the absence of controls, we cannot say that this was the result of scalp cooling. The general opinion is that this procedure has no effect on cyclophosphamideinduced hair loss. Encouraged by other research findings (6), we suggest that the effectiveness of scalp cooling with CMF merits proper evaluation. The breast unit has stopped using scalp cooling with CHOP, but it is offered to patients receiving CMF treatment, who are informed of our findings. Generally, the policy on scalp cooling is to offer it only with chemotherapy regimes for which there is research-based evidence of its effectiveness. We suggest that this policy should be adopted. The indiscriminate use of scalp cooling gives cause for concern, although this is understandable given the general impres sion of its effectiveness created by press coverage. While not doubting the important role which scalp cooling has played and should continue to play in preventing chemotherapyinduced hair loss, research into this procedure has made us aware of its limitations. There is no real solution to the distress caused by hair loss, apart from the elimination of this undesirable side-effect of cytotoxic therapy. What we can do is understand patients’ fears and difficulties and, as sym pathetically as possible, prepare and support them in coping with chemotherapy-induced hair loss. June 12/Volume 5/Number 38 1991 Nursing Standard 31
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Chemotherapyinduced hair loss
Acknowledgments This study was funded, as part of the Nursing Research Unit’s core programme of research, by the Chief Scientist Office of the Scottish Home and Health Department. The views and conclusions expressed are those of the authors and do not necessarily reflect those of the funding body. We acknowledge the assistance and co-operation of all those who supported us in this work, including JAl Health Care who provided equipment for scalp cooling.
Alison Tierney, a nurse researcher, and Jean Taylor, sister ofa specialist unit for the treatment of breast cancer, worked together on a study ofpatients undergoing chemotherapy. Here they describe some of the findings obtained about chemotherapy-induced hair loss and how these have helped nursing staff to be more confident about helping patients with this distressing side-effect of treatment.
Chemotherapy is an increasingly common treatment for many forms of cancer and, for some, it has proved enormously successful. However, this success has been tempered by the unpleasantness of its side-effects. Of all these, hair loss is often the most distressing. The temporary loss of hair may seem a relatively small cost for patients to pay for potentially life-saving treatment, but it can be emotionally devastating. Vicky ClementJones, a young doctor who died of ovarian cancer, said: 'Mentally 1 had prepared myself for the likelihood of losing my hair and having to wear a wig; but the physical reality of the hair falling out posed emotional and practical problems which I had not anticipated. Intell
ectually I knew what was happening, but emotionally it reinforced my feelings that I was losing part of myself (1). It is not difficult to imagine how intense these feelings may be for a woman with breast cancer who, in addition to hair loss, also has to cope with or face the possibility of the loss of a breast through surgery. Although nursing staff in the breast unit where this research was undertaken two-anda-half years ago were well aware of the distress that chemotherapy-induced hair loss can cause, they were uncertain of how best to prepare and help patients to come to terms with it. There were also doubts about whether the unit was making enough and proper use of scalp cooling, a procedure which can prevent hair loss from occurring. Nursing staff now have a more informed and confident approach in coping with the problem of chemotherapy-induced hair loss. Our research in the breast unit, with the co-operation of the patients and staff, has greatly contributed to this. An in-depth, prospective study of 60 chemotherapy JOHN BEHETS
Alison Tierney BSc (Soc Sc/Nurs), Phi), RGN, is Director, Nursing Research Unit, University of Edinburgh. Jean Taylor RGN, is Ward Sister, Breast Unit, Longniore Hospital, Edinburgh.
Scalp cooling pack being prepared.
< A mff x a ■
■
June 12/Volume 5/Number 38 1991 Nursing Standard 29
Downloaded from RCNi.com by ${individualUser.displayName} on Oct 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
CLINICAL ONCOLOGY
m
/
j
JOBS BRUITS
-
Scalp cooling pack being applied.
patients was made on an informed and volun tary basis. They were closely monitored from beginning to end of treatment and in follow up, and their experience and the side-effects were documented. Interest was not confined to the problem of hair loss, although that was investigated in particular detail and is the focus of this article. Readers who are inter ested in the study as a whole, and/or its method and procedures, are referred to the original research report (2). On the subject of hair loss, we collected an enormous amount of data. Once analysed, some of the findings were unsurprising, some provided thought-provoking insights and others suggested obvious ways in which the preparation and support of patients might be improved. We were not surprised to find that for many women hair loss was a particularly upsetting prospect. In pre-treatment interviews, just over a third of the patients admitted to feeling worried and/or upset about hair loss. One patient said: ‘Yes, it worries me because it would be an outward sign of my incapacity and that is upsetting when one is trying to be normal, even with cancer.’ Another confessed: ‘It's interesting because I didn’t expect it would really worry me, but it does . . . terribly. It seems so vain to think like that and 1 don’t know why I’m so bothered about it, but I am.’ A few confessed to having been so distressed about the prospect of hair loss that they had considered refusing chemotherapy. One said: ‘I was heartbroken about it. It really upset me,
to the point of wondering whether I could accept chemotherapy. I couldn't think how I’d cope with it. For me, the possiblity of losing my hair is much, much worse than losing a breast.’ Other patients had obviously worked through such feelings and realised that they could, or at least would, cope with hair loss. There were a number of women who were not concerned about hair loss. One said ‘I’m not worried. It just doesn’t seem important to me.’ There was actually one patient who welcomed the prospect of losing the hair she had never liked!
Individual concerns Although we were not surprised to uncover a great deal of distress about the prospect of hair loss, we soon realised that this should not automatically be assumed, and that the only way to assess individual patients’ concerns is to ask them. Getting patients to talk about their fears and describe their difficulties in coping with hair loss is also therapeutic, and we were informed of a number of practical methods of coping with the difficulties arising from hair loss and the need to wear a wig. Hair falling onto and adhering to clothes, bedclothes and food is a nuisance. One patient found that wearing rubber gloves was an effective way of removing hair from her clothes and pillow-case. Another wore a hairnet at night to avoid covering her pillow case with hair. Many complained that their
30 Nursing .Standard June 12/Volume 5/Number 38 1991 Downloaded from RCNi.com by ${individualUser.displayName} on Oct 30, 2016. For personal use only. No other uses without permission. Copyright © 2016 RCNi Ltd. All rights reserved.
CLINICAL ONCOLOGY
References 1. Clement-Jones V. Cancer and beyond: The formation of BAG UP. British Medical Journal. 1985. 291, 1021-1023. 2. Tierney A J et al. A Study to Inform Nursing Support of Patients Coping with Chemotherapy for Breast Cancer. Fdinburgh, Nursing Research Unit, Department of Nursing Studies, University of Kdinburgh. 1989. 3. Tierney A J. Preventing chemotherapy-induced alopecia in cancer patients: Is scalp cooling worthwhile? Journal of Advanced Nursing. 1987. 12, 303-310. 4. Hunt J M et al. Scalp hypothermia to prevent adriamycin-induced hair loss. Cancer Nursing. 1982. 5, 25-31. 5. Middleton J et al. Failure of scalp cooling to prevent hair loss when cyclophosphamide is added to doxorubicin and vincristine. Cancer Treatment Reports. 1985. 69, 373-375. 6. Parker R. The effectiveness of scalp hypothermia in preventing cyclophosphamide-induced alopecia. Oncology Nursing Forum. 1987. 14, 6, 49-53.
wig was either too hot or too cold, depending on the weather. Some found that wearing a scarf or hat added warmth. The insertion of a cotton lining reduced perspiration in summer and helped prevent the itchiness which many patients found particularly irksome. Restrictions on activity were another diffi culty, especially for a patient whose life centred on outdoor bowling and others who liked swimming regularly. Washing and styling was a practical difficulty and caused anxiety. One patient said: ‘I was terrified to wash the wig because I had to keep it wearable all the time for work. 1 washed it for the first time last weekend and was really anxious in case it fell apart. It didn’t do that but it did take ages to dry.' In the recommendations of the research report we suggested that consideration should be given to the provision of a second wig for patients, and that they should be offered advice and practical instruction on washing and styling. It is not so easy to suggest specific methods to alleviate the emotional problems many women encounter with hair loss and in having to wear a wig. Being encouraged to talk about these and knowing that there is a sympathetic ear seems to help. When hair loss was severe and sudden, as opposed to gradual thinning, most patients found the experience traumatic. One said: 'It was dreadful when it happened. It started so suddenly and just fell out in handfuls, and I was bald within a couple of days. 1 was absolutely shattered. 1 hadn’t expected it to be so awful.’ Once over the worst, many seemed to come to terms with the loss of their hair remarkably quickly and soon became accustomed to their wigs. For a few, however, the misery lasted longer. One patient said: ‘I'm managing, and managing the wig, which everyone says looks nice, but no-one knows the private agony.' We would all like to spare patients the experience of chemotherapy-induced hair loss. In pursuit of this goal, scalp cooling was introduced into the breast unit some years ago. Its use was spasmodic, however, because enthusiasm lapsed whenever it did not seem to be working. For the research study period, it was decided that a concerted effort would be made to use scalp cooling routinely and to monitor the outcome consistently. In prepara tion, all available literature on scalp cooling was reviewed (3) and guidance was sought from nurses at The Royal Marsden Hospital, where important original work on this has been carried out (4). Although all but three of the 60 patients elected to begin with scalp cooling, almost
half discontinued after one application. In almost all these cases hair loss had occurred, or was starting, by the time the second chemo therapy was due. The chemotherapy con cerned in all of these cases was CHOP (IV adriamycin 50mg/m2 in combination with cyclophosphamide lgm/m2 and vincristine 1.4mg/m2, supplemented by oral predniso lone 40mg for 5 days). CHOP was adminis tered to 32 patients and, by the end of treatment, 27 of these had total hair loss and three had severe hair loss, also requiring a wig. Although we did not use a controlled trial, our conclusion that scalp cooling is not effective in preventing CHOP-induced hair loss concurs with evidence from other reported studies (5).
No effect In contrast, mild hair loss, if any, was experienced by patients in the research sample who were receiving the other main chemo therapy regime employed, CMF (IV cyclo phosphamide 600-75()mg/m2, methotrexate 50mg/nV and 5-fluourouracil 600mg/m2). Of the 21 patients in the sample who were treated with CMF, five had no loss of hair and 15 only had mild hair loss. In the absence of controls, we cannot say that this was the result of scalp cooling. The general opinion is that this procedure has no effect on cyclophosphamideinduced hair loss. Encouraged by other research findings (6), we suggest that the effectiveness of scalp cooling with CMF merits proper evaluation. The breast unit has stopped using scalp cooling with CHOP, but it is offered to patients receiving CMF treatment, who are informed of our findings. Generally, the policy on scalp cooling is to offer it only with chemotherapy regimes for which there is research-based evidence of its effectiveness. We suggest that this policy should be adopted. The indiscriminate use of scalp cooling gives cause for concern, although this is understandable given the general impres sion of its effectiveness created by press coverage. While not doubting the important role which scalp cooling has played and should continue to play in preventing chemotherapyinduced hair loss, research into this procedure has made us aware of its limitations. There is no real solution to the distress caused by hair loss, apart from the elimination of this undesirable side-effect of cytotoxic therapy. What we can do is understand patients’ fears and difficulties and, as sym pathetically as possible, prepare and support them in coping with chemotherapy-induced hair loss. June 12/Volume 5/Number 38 1991 Nursing Standard 31
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