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Dr. John Leonard (Host): Welcome to Weill Cornell Medicine Cancer Cast: Conversations About New Developments in Medicine, Cancer Care, and Research. I'm your host, Dr. John Leonard, and today's topic will be new strategies to prevent chemo-related hair loss. My guest today is Dr. Tessa Cigler. Dr. Cigler is the Clinical Director of the Breast Center at Weill Cornell Medicine and New York Presbyterian Hospital. She cares for patients will all stages of breast cancer, and conducts research focused on improving quality of life, as well as aspects of disease treatment and prevention.

Notably for today's discussion, Dr. Cigler leads several clinical trials designed to provide breast cancer patients with access to the most promising therapeutic options, and she was instrumental in the pilot study that led to the FDA approval of a novel scalp pulling system used to prevent chemotherapy-related hair loss. So Tessa, thank you for being here today with us. This is a really important topic obviously for patients. I actually just left a patient, talking to her about therapy, and her concerns about hair loss understandably were a big part of the discussion, so thank you for joining us.

Dr. Tessa Cigler, MD, MPH (Guest): Oh, it's my pleasure. It's a topic that's near and dear to my heart.

Dr. Leonard: So I guess by way of background, oncology is broad, you work in breast cancer. Obviously this is an area that is important to patients, but perhaps is understudied. How did you kind of find yourself focusing in part in this area and working in this to try to help your patients?

Dr. Cigler: It's a good question. You know, I'm a busy medical oncologist, I treat a lot of patients, and I think the focus is always getting the best outcome for the patients. And I had a young patient in the beginning of my career who needed chemotherapy for her early stage curable breast cancer, and she came to me saying, "I just- of all the side effects of chemotherapy, hair loss is the most petrifying and seems the most devastating to me, and I just can't undergo it."

And she- we spoke about the risks, and the problems with that, and how we could ameliorate the situation to allow her to receive this - what I felt was - lifesaving chemotherapy. And she was an amazing brilliant young woman, and she did all her research, and came back to me to say, "You know in Europe, for many years they've been using this thing called a cold cap." And I must have looked at her like she had eight heads. And it was really through her that she introduced this topic of cold caps and started us and our program on a decade of interest and research on this topic.

Dr. Leonard: So obviously this is an important issue for patients, and we're going to talk a little bit about these new strategies, and how we get there, and the impact on patients, but I guess the first question to introduce the background of the topic is certain chemotherapy drugs cause hair loss, certain don't. Kind of explain to our audience a little bit about why chemotherapy or certain chemotherapies cause hair loss, and how that's connected to their patient therapy.

Dr. Cigler: Yeah, so on the most basic level, chemotherapy works by preventing rapidly dividing cells from growing. We believe that most cancers are rapidly dividing and so that's why chemotherapy is effective against cancer cells. But hair follicles and hair cells are also rapidly dividing, and so chemotherapy is particularly toxic to those cells, which is why most chemotherapy agents are associated with hair loss.

Dr. Leonard: So the differences between certain drugs that don't cause it and certain do, it's just a matter of the mechanism of action of chemotherapy primarily?

Dr. Cigler: Exactly.

Dr. Leonard: Okay. So patients often ask also, and I'm sure you have your own stories around this, from the standpoint of, "Well I didn't lose my hair," or "I really lost my hair a lot. Does that mean it's working or not working?" Not a lot of correlation with efficacy, is that your impression as well?

Dr. Cigler: Yeah that's absolutely true. So some chemotherapy agents do cause hair loss, some don't cause hair loss, and the degree of hair loss that a woman or person experiences is not related to the effectiveness of the chemotherapy.

Dr. Leonard: Great. So obviously this is a major issue, and I'm sure there have been a variety of different attempts to minimize chemotherapy-related hair loss, which in my experience, has largely been around changing the drug- the chemotherapy itself. In other words, developing a new area, a new type of drug in the same class that perhaps could be as effective but doesn't cause hair loss. It seems to me like in some cases that works, but in other cases you're still compromising efficacy if you substitute a new drug in. And I know there have been some examples of doing that in breast cancer, that sometimes that swapped in new drugs but sometimes happen. Is that fair to say?

Dr. Cigler: Fair to say. You know, there are situations where it's perfectly appropriate to choose one drug over the other based on which drug may or may not cause hair loss. But for many women, especially for the bulk of women with early stage breast cancer, the chemotherapy programs we have do cause hair loss, and it really wouldn't make sense to substitute other drugs for those drugs, or to compromise the treatment and the potential for a cure to minimize hair loss.

Dr. Leonard: So I think it's important for patients to understand that all chemotherapy is not the same in this regard. They should talk to their doctor about the issue, but the idea of substituting in something with less hair loss as far as the therapeutic drug sometimes is appropriate, but often it's not, and so that brings us to the scenario where we need to use a drug for the best cancer-related outcome that causes hair loss, and the strategies to kind of ameliorate that. And so that brings us to scalp cooling therapy, and can you tell us a little bit about- I mean this seems to be the approach that's the farthest along as evidenced by the fact that it's gaining acceptance. But how does this work? 

Dr. Cigler: Right so scalp cooling was actually introduced in Europe and it's been used in Europe since the 1970's. And it's only in the past several years that it's really gained more widespread attention in the U.S. The idea of scalp cooling is actually a very simple one. If you freeze the scalp and make the hair follicles really, really cold, you cause the blood vessels in the hair follicle to constrict, to narrow, and that reduces the ability of the chemotherapy to penetrate into those hair follicles, and thus prevents the chemotherapy from causing hair loss. And also the very cold temperatures from scalp cooling in a sense put the hair follicles to sleep and stop them from being able to be affected by the chemotherapy.

Dr. Leonard: So what does that mean practically for a patient? What does- when your patients- and you have a lot of experience with having patients go through this treatment. What on the day of treatment is kind of the practicalities of a patient in setting all of this up, and how does it affect their treatment itself? Obviously when patients are getting chemotherapy, it's a busy day, a lot of different treatments, they're anxious, they have a lot going on. Tell us about the mechanics of this from the patient's perspective.

Dr. Cigler: So there is no doubt about it, that using scalp cooling is a big hassle. There are two types of scalp cooling devices. There's a manual type and the more recently automated type. The manual type is essentially a gel cap that patients wear on their heads before chemotherapy, during chemotherapy, and after chemotherapy. And that's important because obviously scalp cooling then takes up a lot of extra time.

These manual caps have to be frozen the night before to extremely cold temperatures, temperatures that a regular freezer can't get to. So in order to use the caps, one needs a specialized freezer and/or dry ice brought to the center. As soon as the caps are placed on the head, they lose some of their coldness, and so these caps have to be replaced every thirty minutes during the treatment, so it's quite a laborious process. The caps are put on thirty minutes before treatment, rotated every thirty minutes during treatment, and worn for two to three hours after treatment.

Dr. Leonard: So do you have to have somebody with you that's kind of doing all of this for you? I know the nurses giving the chemo are obviously busy with making that go smoothly. How does that work for most people?

Dr. Cigler: Yeah, it's absolutely essential to have- we call them cappers, and that capper can be a trained individual who's used to doing it, or many of our patients have family members or friends who do it for them. The automated process is, as it sounds, much easier, it's automated. The automated- the machines are essentially caps fitted to a small refrigeration unit and coolant is run through a hose and that cools the cap. The machines don't require the caps to be changed at all, so a person puts it on his or her head at the start of- before chemotherapy, and wears it throughout. The machine versions are not nearly as cold as the caps.

Dr. Leonard: So Tessa, I know that you and the Breast Center here at Weill Cornell and New York Presbyterian have been amongst the pioneers of this. Roughly how many patients have you treated? I know you have a lot of experience with it.

Dr. Cigler: Gosh, we've treated hundreds of patients with scalp cooling at our center.

Dr. Leonard: Really? And at this point, and we'll talk a little bit about what the FDA has approved, but is this available at many other centers or it's increasing? Or if people are in a community center, is this something that they ask their doctor about, they're likely to be able to get? Or is it really just in a few places at this point?

Dr. Cigler: Cold cap therapy is gaining a lot of popularity and quickly around the country, but it is not nearly available everywhere. It's also not, as of yet, covered by insurance, and we're working hard to make that happen in the near future.

Dr. Leonard: And do you have a ballpark of the cost roughly?

Dr. Cigler: Yeah, so as you can imagine it ranges across the city, across the country, and between cities. In the New York area, caps are very costly, and a course of treatment with caps can range anywhere from $2,000 to $5,000.

Dr. Leonard: Okay, so obviously in making that decision, and perhaps finding a center that has this available, the obvious question is well how well does it work? What's the chance that someone is going to have partial hair loss? What's the chance that someone's going to have total hair loss? And I get that there's probably some rigorous or semi-rigorous ways of measuring the degree of hair loss to tell a patient, "Yes, this is going to work well enough that it makes sense to consider doing." How do you kind of explain that to a patient in general?

Dr. Cigler: So the success of cold caps really depends on the type of chemotherapy. And so the anthracyclines are a class of chemotherapy often used in breast cancer for which the caps don't work as well. For the common breast cancer treatment programs, we quote a rate of- at our center of about 80% success rate, and success can be defined in many ways. The way I like to define it is whether or not a person feels the need to wear a head covering or wig during or at the end of treatment.

You know, there have been two prospective clinical trials which have rigorously evaluated  these scalp cooling- of two scalp cooling devices. And in these trials, they measured success as rate of hair loss of less than 50%. So for women- these were studies done in women with breast cancer, and those women who were able to keep 50% or more of their hair were considered to have success with the scalp cooling. And in these studies, each with over 100 patients with breast cancer treated with chemotherapy, the success rates were in the range of 50% to 60%.

Dr. Leonard: So would you say that most patients who choose to go through this are more or less happy with the results and look at it as a good experience from the standpoint of at least that part of their treatment? Or what's kind of the general feedback you get from patients on this aspect of their care?

Dr. Cigler:  Uniformly we've noticed that patients who choose to undergo scalp cooling, regardless of the results, are really unbelievably grateful for having had the opportunity to do that.

I think being able to take control of a devastating side effect is very empowering for women. For women who are able to keep their hair during chemotherapy, it allows them to maintain their sense of self-esteem, their sense of well-being, and confidence as well as privacy during what can be a really difficult time.

Women choose to undergo scalp cooling for many reasons. A lot of our patients who have young children at home like to protect the children from the fact that they're undergoing treatment. We have women who continue to work full-time and don't want their jobs to be jeopardized in any way because they're perceived as being sick. We have women who are dating who hair loss would be a big problem for their social life.

Dr. Leonard: So from the standpoint of- my understanding is that there's been some - for lack of a better term - clearance of this by the FDA of at least one of these approaches. Can you tell us a little bit about what that means? Or how that impacts the availability of this sort of treatment?

Dr. Cigler: Yeah so based on these two prospective studies that were published in one of our big medical journals last year, the FDA did provide clearance for two devices - the DigniCap and the Paxman Device - first for women undergoing chemotherapy for breast cancer, and now that clearance has been expanded to all patients with solid tumors.

Dr. Leonard: So we talked a bit, and obviously this has been studied, and your focus is primarily on breast cancer and women obviously. What other areas as of now at least is this sort of approach available for? Who would you say should speak about this specifically beyond breast cancer patients with their doctor?

Dr. Cigler: I think individuals undergoing- individuals with solid tumors. So these are the tumors that are not leukemias or lymphomas at the moment such as breast cancer, ovarian cancer, endometrial cancer, lung cancer, prostate cancer. Many of those chemotherapy programs would render themselves- for many of those- I have to pause here. For patients undergoing treatment for lung cancer, uterine cancer, ovarian cancer, men with prostate cancer would all be potentially candidates for scalp cooling.

Dr. Leonard: So you mentioned a number of areas where this may be appropriate to consider. Obviously there are at least theoretically some diseases where this is not an appropriate strategy, and that may be because it's not going to work, or not going to be effective, but also that it may potentially interfere with or impact the treatment of the underlying disease. What are the current thoughts about that? And I know that there's research going on there, and we have talked about in our lymphoma program at least exploring the potential for this type of technology for some of our patients, and that's all in an early stage. But what are at least the concerns about including some patients in this form of therapy at this point in time?

Dr. Cigler: The biggest fear of scalp cooling is that perhaps if there are cells- cancer cells that are in the scalp, by limiting chemotherapy penetration to the scalp, you might not be targeting those cells. And it's a theoretical concern that physicians have had over many years. At least for solid tumors, we now have results of two large studies suggesting that scalp metastasis or cancer cells coming back in the scalp has not- there's not a higher incidence of that among individuals treated with scalp cooling. And we have a recent big analysis called a meta-analysis where data from thousands of women are pooled together, and really that meta-analysis was very reassuring to us in the breast cancer world that the incidents of scalp metastasis are very low to begin with, way less than 1%, and that rate is not increased by the use of scalp cooling.

Dr. Leonard: So as of now, I think then the recommendations are at least until we have more information that patients with leukemia and most likely patients with lymphoma, other blood cancers, those are the key patients where this would be excluded largely until we have more data. Is that fair to say?

Dr. Cigler: I think that's fair to say.

Dr. Leonard: Great. Great, so what do you think the future is going to be from the standpoint of- obviously cancer care is evolving, our drugs are evolving, presumably we'll have more treatments that will not have hair loss as a side effect. But do you think that this is going to make its way into the mainstream more and that more and more patients with more and more disease types will be at least candidates for this sort of therapy on a more routine basis?

Dr. Cigler: Absolutely. I think scalp cooling is hair to stay. Scalp cooling is not going anywhere. Patients more and more are going to demand it, and I think physicians in cancer centers across the country are going to have to change their practices to allow scalp cooling to happen.

Dr. Leonard: Well thanks for advancing this area, and just before we wrap up, I just would- I know that a big focus of your practice and some of your research is around bringing new options to patients, supportive care, wellness, quality of life, and aspects of that in your practice at the Breast Center at Weill Cornell and New York Presbyterian. And you know, I'm interested to hear your thoughts just briefly on kind of what are some of the other things that you and your group are doing. Obviously hair loss is part of- obviously a difficult part of the cancer experience, but other things that you're doing that you think can make a big difference for patients as they go through their treatment program, whether it's breast cancer or other malignancies.

Dr. Cigler: I think more and more, particularly in the field of breast cancer where we have so many long-term survivors, we are focusing our attention to quality of life both during treatment and beyond. The Cornell Breast Center has a staff that includes social workers, nurse navigators, massage therapists, we have a complimentary medicine center available to patients with acupuncture, and massage, and a whole host of complimentary therapies to help improve their quality of life and symptoms during chemotherapy and afterwards as well.

Dr. Leonard: Well I want to thank you for joining us here today. It's been really great and we spend a lot of time talking about how we can cure more patients, and obviously that's important, but I think helping patients through the treatment experience, and making it easier and less challenging for patients to deal with some of these difficult side effects is obviously very important. And I want to thank you for sharing your thoughts with us today as well as all of your work in this area.

Dr. Cigler: My pleasure, thanks so much.

Dr. Leonard: So this concludes our episode for today. I want to invite the audience to download, subscribe, rate, and review Cancer Cast on Apple Podcast, Google Play Music, or online at www.WeillCornell.org. We also encourage you to write to us at This email address is being protected from spambots. You need JavaScript enabled to view it. with questions, comments, and topics you'd like to see us cover more in depth in the future. That's it for Cancer Cast: Conversations About New Developments in Medicine, Cancer Care, and Research. I'm Dr. John Leonard, thanks for tuning in.