Educational webinar: Scalp cooling

Good afternoon. Thank you for joining us today. My name is Brandon Martin here at mckesson Medical Surgical and I'm so excited to welcome you to today's presentation scalp cooling for the prevention of chemotherapy induced alopecia brought to you by cooler heads. Before we get started, I'd like to direct your attention to our disclaimer while you're reviewing that information. I will remind you that today's presentation is being recorded within a day or two. You can expect to receive a link to download a copy of the presentation. You can also download the slides by following the link under the presentation materials to the left of your screen. If you have a question, feel free to enter into the Q and A panel at the bottom left corner of your webinar window at any time and we will do our best to answer at the end of the presentation. Our speaker today is Doctor Jennifer Graf. Doctor Graf is a board certified obstetrician and gynecologist. She grew up in Scottsdale, Arizona, attended Texas Christian University, University of Kansas Medical School and then did her OBGYN residency training in San Antonio Texas. She received uh achieved top 5% medical school honors, received the gold Humanism Award in residency and was voted best volunteer faculty teacher for multiple years from the University of New Mexico Residency Program. Doctor Graf. Thank you so much for being here today. We are looking forward to your presentation uh without any further ado the floor is yours. Great. Thank you so much. That was a very kind introduction and I'm very excited to talk with you this afternoon about scalp cooling for the prevention of chemotherapy induced alopecia. Uh It's something that is offered in many uh main infusion centers across the nation and now it's getting into smaller infusion centers. So more people are able to have access to this wonderful treatment. It's also taking social media by storm. Uh There's a social media platform that has over 9000 members and another one with 5500. So it's definitely something patients are asking about. So, um as it was mentioned, my name is Doctor Jennifer Graf and I work in Flagstaff Arizona and I'm sure you're wondering why is an OBGYN speaking with you about um a, a chemotherapy or oncology topic? And uh so unfortunately, approximately about a year ago, I was going in for my normal screening. MRI I was getting every six month screens because of my high risk due to family history and dense breast tissue. So it had a normal mammogram about eight months prior. And when I went in for my MRI, uh it looked a little funny. So they did a biopsy and uh it looked like cancer. So my uh oncologist recommended 12 weekly doses of Taxol and Herceptin. And I'm currently undergoing about every three weeks a Herceptin to complete a year. So, uh fortunately it was an early state. Um, but it definitely made a huge impact on my life. And when uh my breast surgeon found out that I would have to do chemotherapy, she told me I should cold cap and I had never heard of it before. And now I feel quite embarrassed that I had not heard of it before considering I have to call or talk to women and tell them that they have breast cancer every year. So the fact that I didn't know about it, um, I, I, yeah, a little embarrassed about that but, um, when, when there's something I don't know about, I go to do research and that's exactly what I did and that's when I chose to do, um, cold capping with a, a bi cooler heads. So why did I choose the cold cap? Obviously, there's lots of reasons that go into it. Uh But as a mom, my first thoughts always go to my Children. My Children have only known me as having long hair and I knew that seeing me without hair would be traumatic and I happen to be married to a child and adolescent psychiatrist. And so I hear about childhood traumas, all the time and I know that when you add up all these different childhood traumas, then that if ends up affecting their chance for success later on as adulthood. And I didn't want my diagnosis to have, uh it was already gonna be a trauma knowing that their mom had cancer, but I didn't want it to be overly traumatic. Um looking at me every day and wondering if I was sick. So secondly, I am an obgyn. I take care of patients in some of their most vulnerable times and they looked, my patients looked to me and have confidence in me to deliver a happy healthy pregnancy, happy healthy baby. And I was very concerned that if I lost all my hair, my eyelashes and and my eyebrows that I would look sick and that they, you know, while I knew that they would have empathy, I wasn't sure they would feel confident that I would be able to deliver them that outcome of a happy healthy baby and a happy healthy mom. So, um I didn't want that to be a problem and I it also would have been a financial impact for my practice to lose patients potentially. So thirdly, I live in a small town and um privacy is important. But if any of you live in a small town or watch enough Hallmark commercials about small towns, then you know that everyone knows everything in a small town. And I this was such a jarring thing to my life that I really didn't want everybody coming up to me and asking me like, oh, how are you feeling? How are you doing? I just wanted to be able to escape uh, into my work and because I was already thinking about it 24 7 when I was at home, I didn't want to think more about it all the time when I was at work and having patients ask me about it. So the privacy was a huge deal. I really wanted to have control over something since I didn't have control over so many other things. And lastly, I did it for me. Uh my kids obviously look at me with having long hair, but I've always had long hair and I identify with uh having long hair. So I knew that looking in the mirror and not having hair would be really traumatic for me and that it would kind of be a constant reminder. I knew it would take about 6 to 8 years to get my hair back to the length that it was. And I just felt like it would just be a daily reminder that I had cancer and I really wanted to get my treatment taken care of. I wanted to move on and look at the future. So the process, uh there are basically two types of coal capping. There's the manual based coal capping and the machine based coal capping. So the top three companies in the United States uh for machine based are Amaar heads, Paxman and Dignity cap. And then the two most common for manual based are Penguin and Arctic. So, um in manual based co capping, it's pretty labor intensive. So what happens is the patient gets dry ice the night before and um she packs these wraps, these iced wraps in the dry ice and then during treatment, she has an assistant um and the assistant has to lay out the wraps and I, I've seen lots of videos on it. The assistant has to kind of use physical force to kind of mash down the, the ice wraps so that it can be more malleable and, uh, be able to be applied to the patient's head and that has to be switched out about every 25 minutes. So it's really labor intensive with the machine based. Uh, it's, it's different. The most of the infusion centers have the machine. The patient gets a kit, including a cold cap that fits them. They have different sizes and she brings that cold cap to the facility, hooks it up to the hose and presses a button and it's a much simpler procedure. You're not taking on a wrap and putting one back on. It's just 11 step. So for me, uh, ha, having to do manual would have almost been a been no go, I wouldn't have been able to, to do that. Um, my husband was already taking off plenty of time from work um, to try to be available, but that would have just added even more time. So I'll focus mostly on the how you do the machine based pool capping. The first thing is that the patient won't wet their hair. Uh, patients can either have a spray bottle to wet their hair. I like to just go ahead and take a shower at the morning of my infusion, get my hair wet, not wash it, but get it wet and then wear a sh a shower cap and like a beanie over it which, uh, kept my hair wet while I went in for my lab, draw my meeting with the oncologist and then when I was ready to start therapy, um, secondly, you apply a little mole skin right over the fore forehead to protect the bare skin from any, um, cold damage. And then you apply the cold cap and the cold cap has, uh, a velcro so that you can adhere it and make it very snug on the head because that's the most important part. Once the cap is firmly in place, then the patient hooks up the hose to the machine and the liquid gets circulated through the cap. Um, followed by a second cap. That's a compression cap over that to make sure that there is a, a good snug fit when patients are cold capping, they are supposed to avoid any stressors on the hair and that includes, um like hair drying, dying their hair, uh they shouldn't be curling or styling their hair and they should minimize uh washes to about 1 to 2 times a week. So in terms of cold capping experience, most patients find it um very reasonable. The most commonly encountered side effects include headaches, neck and shoulder discomfort, chills and scalp pain. I uh was really lucky. I was really nervous about just feeling cold. I really hate being cold and I thought just sitting there for hours with the cap on, I thought I would be freezing, but it really wasn't. I just wore a fleece top and pants and I had a heated blanket and, um, I didn't have any pain on my head. I didn't have any headaches. I didn't have anything like that. II, I almost wondered if it was working because it was so well tolerated. Um, and I was really lucky. Now, the icing in my hands and feet, which I also did that was way more uncomfortable. Um, that was quite uncomfortable, especially on the hands, but the scalp pulling it, I, I did really well super lucky. So this is a study out of Jama and it's, um, was showing, uh, the effects that some people experience with both the manual and the machine based cold capping. Um, it was called the scalp trial. And as you can see, uh, all three had both headaches and a general discomfort of feeling cold. Approximately 25% of the participants did discontinue cold capping due to headache. Um Some other things with the manual based cold capping, some dizziness, nausea, vomiting, um and cold thermal injury. The manual based cold capping does tend to be a little colder on the scalp. And so there is that uh little bit risk of that frostbite. Um with a manual based cold capping, they're attempting to get the scalp to about 64 °F. So you can see uh the results from my cold capping. Uh You can see there on the left my before picture and after and I would say during chemotherapy, I lost probably about 10% of my hair and then over the next about eight months or so, maybe an additional 20 to 30%. But nobody could tell um my kids couldn't tell, um patients couldn't tell nobody, nobody could tell it was about me. I was the only person that could notice. So I'd like to kind of change uh topics a little bit for myself and do a little more discussion um so that you can generalize this to your patient population. So the first thing to look at is who's the appropriate patient, right? Who can cold cap? So it needs to be a patient that has solid cancer tumors that are undergoing chemotherapy that causes alopecia. There are um different contra contraindications, but these are the ones that uh are the most common. So anybody that has a head and neck cancer or any cancer that has a metastasis to the head or neck would not be a candidate. Uh people with skin cancers are also not candidates and uh people with a diagnosis of small cell lung cancer would also be contraindicated. So, in 2019, uh there is a published publish that said approximately 65% of patients that undergo traditional chemotherapy have alopecia and of those some have a risk of permanent hair loss. And fortunately, the permanent hair loss is not common, but it does happen. And I had a personal experience with that. Uh one day in my office, I walked in on Halloween and in our office, we all dressed up for Halloween and I turned to one of our front office ladies and she was dressed as Mr clean and with a bald head and all. And I was kind of taken back a little bit and said, wow, great costume. And she's like, oh, you've probably never seen me bald before. And I was like, no, I have not. And she told me that she had had cancer and she underwent chemotherapy and her hair never grew back. So um it is uh definitely something that does happen sometimes. Uh the, the same study that said that approximately 65% of patients undergoing the chemotherapy will have alopecia. Um It showed that 40 to 100% of women undergoing breast cancer uh chemotherapy have complete alopecia. So the majority of patients um report that hair loss is the most traumatic aspect of chemotherapy. And this was in um the journal of Clinical Oncology in 2005. Uh up to 8% of patients. So almost like a 10%. Um a number of patients will specifically decline chemotherapy due to their concern about possibly having a hair loss. Ok. So enough of the depressing part about hair loss, let's have a ray of hope. Let's talk about how we can uh dramatically change a patient's experience with chemotherapy. I was definitely looking for a ray of hope when I got my diagnosis, which I definitely was ex when I wasn't expecting. Um I was told it was probably DC is well, then I had my surgery, it wasn't D CS, it was invasive. And then even though the DC is had been hormone receptor positive, the invasive part wasn't. So that was also a downer and then it was her two positive and that meant it had a higher chance of recurrence. So I was just like getting one bad news after another and when I heard that I had to have chemotherapy, that was really hard because I just automatically thought of the bald head. So when I heard about cold capping, it was like a ray of hope. It was like the first time I smiled in a month and then when I heard I might be able to do machine based cold capping. That was just, it was like the best day that I had in so many days. And uh I really hope that a lot of people will have the um opportunity to do co capping if they choose. So. Uh a lot of people probably have some guesses about how cold caping works. And we believe there are two ways. One is vasoconstriction. Obviously, if you reduce the blood flow to the hair follicles, you're reducing the amount of chemotherapy that's getting to those uh hair follicles. And secondly, when you cool down tissue, your meta metabolism in those those cells is slowing down too. And so the hair follicles are less susceptible to the damaging effects of the chemotherapeutic agents. All right. So I might be showing my age a little bit here. But um if anybody remembers Jerry Maguire the movie, uh you know, I I know you wanna see the data, right? You, you're hearing what I'm saying, but you wanna see the data. So the big trial was produced in Jama in 2017 called the Scalp trial was a randomized clinical trial. They had 100 and 82 women and all the women had uh stages 1 to 2 breast cancer. Uh They had about 100 and 19 women who were in the scalp cooling group. And um about half of that in the control group in the final count, they had about 100 and 42. They had about uh 30 women who uh chose not to do the cold capping after randomization, but prior to chemotherapy, so about 50% of the the patients in the scalp cooling uh section lost less than 50% of their hair versus 0% in the non cold capping group. So the study had been desi designed that they could stop early. And when they did their interval analysis, uh which they did, they just showed too much efficacy from the scalp cooling to continue the study. So they ended that early. You can see in this study um published just last year in breast, it was looking at 100 and 28 patients, they had about 88 that cold capped and about half of that that were in the control group. About if you look at the blue and gray lines, those are the women that cold capped and retained at least 50% of their hair. So there was 13% that had no hair loss and 59% that had less than 50%. If you look at the right side, you can see that the hair loss when they did not cold cap was 100%. So as I was doing more and more research, I definitely think that it's important to choose the right patient. So there are, I looked at this study and you could see that when patients did attacking monotherapy, then they had about a 50% chance of having no hair loss or less than 50%. If they did both the taxing and the anthracycline, then it went down to about 17%. But that's still close, you know, close to 1/5 of all your patients. That's, that's something that is to take into consideration. What's also interesting is if you look a little bit further into that cold capping group, it did depend on how the treatment regimen was given. So if they started out with the Taxol and then followed with the Anthracycline, then they had about 40% of the women who had less than 50% hair loss if they didn't. Um Anthracycline first followed by the Taxol. It went down a little bit to 20%. But if the patient was receiving both simultaneously, it went down to about 4%. So if the patient that you're seeing has uh a regimen with both the Taxol and the Anthros Iine together, it may not be worth uh it to her to only have a potentially 4% chance for um, not losing much hair. And then you can see at the bottom, the blue and the green arrows under the non cold cap. So they had 0% of women that lost less than 50% of their hair. They all had at least grade two alopecia, which was more than 50%. All right. So this was another study. It was a me analysis of 53 publications and the anos oncology and it was looking at, um, the cool versus the control group over, um, on the highlighted area. And in the cold capping group, they had anywhere from a 10 to 100% success with cold capping. Um, m most of them were above the 50th percentile in terms of having success versus the parentheses. That that's the non cold capping, the controls and that was anywhere from 0 to 63 but it really was more like 0 to 20%. There was only one study that was above 20%. So kind of an outlier there. And also what was interesting was it looked like Doctor Robison appeared to have the, that was the toughest on hair, which I'm sure many of you see in clinical practice. So there was a, a study by MS Dad that looks at 29 women who had gynecologic cancer and complete alopecia and they found that about 73% of the women, they lost their confidence, they didn't feel um as good as they had prior to treatment. So that's pretty significant. And for about half of those women, the hair loss was the most traumatic side effect of chemotherapy. So I know a lot of people think of hair loss, but they also think of nausea and fatigue and everything. So it's pretty substantial that about half of them thought that the hair loss was the most traumatic side effect. So especially in today, uh we really try as physicians to treat the whole patient mind, body and soul. And uh I think it's really important that we take into consideration the mental aspect of losing hair, not just the physical. And I was trying to think, uh how I can compare that to my practice in obstetrics, obstetrics and gynecology. So, you know, they, they definitely want a happy healthy baby with me, just like with cancer treatment. They're, they're hoping that you're curing them, they're hoping they get the best possible outcome. And on the other side of treatment, um, you want your patient to get back to themselves to be able to recognize themselves in the face, in, in the, the mirror. And um, just like, uh when I deliver a patient, I want her to get back to her normal as well. So if she ends up with ac section, she's gonna have a big scar in her tummy. So I try to do a really nice closure because that's the last thing she's gonna see. That's what she's gonna think of me. Um, when she looks in the mirror she's gonna think, oh, Doctor Graf did a really nice closure. My scar looks so good in oncology. You know, they're gonna be looking in the mirror after their treatments and they're gonna see, you know, either the person they saw before or they're gonna see that they're quite changed and hopefully we can help them feel a little bit more normal after having to go through such a traumatic experience. So, um I know this is brief, but I wanted to give you an overview of cold capping for chemotherapy induced alopecia. And uh thank you for listening. This is my family, my 13 and 15 year old and uh I think we might have done a too good of a job of trying to shield them from my diagnosis because they, they sailed through it way better than I expected. So, if anybody has any questions, then I am happy to answer those. Thank you so much, Doctor Graf and, and thank you uh for sharing your own personal journey uh through this experience. And I really appreciate your time today and, and your insight. Um We do have a number of questions that have come in and just a reminder to our audience. If you do have a question for Dr Graf, you can find the Q and a window at the bottom left of your screen. Uh And I'll go ahead and go through some of these questions. Of course, if there are any that um uh that you're not prepared to answer. If it's, you know, if it's for the cooler head staff or anything like that, then certainly we can uh connect anyone in the audience. Uh following the presentation. There will be a number of uh emails that you'll receive with recordings and information for uh contacting that team. So, uh let's just start at the top here. Could you maybe talk to us a little bit about the, um, type of support uh as a patient um, that you receive, especially if you have questions that come up during treatment. Yes, absolutely. So, when I started the process of using the cooler heads, uh alma by cooler heads, we had a in depth um telemedicine meeting where we went over me applying the cold cap. My husband was there, my nurse, um Navigator was there and we kind of went through the steps and um I was sent a kit which had very detailed guidelines about how to um fit the cap, how to um place it and to, to go through the process. Um the first day, you know, I think everybody's nervous about infusions and different things going on. So it's uh in my case, actually, the the cold capping was the easiest part of my first day. But um they for, with cooler heads, at least the first day, I actually had somebody from cooler heads there. Uh that was able to um answer any questions, but we did, we did great. We actually between my husband and myself, I didn't even have my nurse Navigator there. So we felt plenty supported. Um So um beforehand going in, we, we kind of felt like we, we knew what we were doing. Um I, I know that at least with cooler heads, they have great resources for the patients for the nurse navigators. Um They're very quick at responding to any questions or concerns and um very committed to making sure that people have a good outcome and, and a good experience. Uh So I think they do a good job making sure that the staff is prepared as well when they're introducing uh machines, coal capping to an infusion center so that the people feel comfortable. Uh We have some people doing cold capping in my, my clinic now or in my infusion center. And I was expecting them to call me all the time with questions. But the nur nurses there, they, they are doing really well with it and haven't needed any of my help. That's fantastic. Um So can this technology um can this be used for any other kinds of hair loss or alopecia? Uh That's a really good question and I, I won't answer as a clinician, but just as a theoretically, I would imagine that anything that is reducing um injury to the hair follicle. So if there's a known uh chemical or no known something that is going through the bloodstream, uh it would make sense that those two principles, the vasoconstriction and the the reduced metabolism would be um efficacious, but maybe the person asking the question can give me a specific of what they're wondering about. Sure. Um Let's see. I'm just scrolling through the, the um you, you mentioned uh the hands and feet cold therapy. What, what was that for. Yeah. So some of the chemotherapy agents can cause neuropathy uh especially in the hands and feet. And so the same principle trying to reduce the amount of chemo that gets to the hands and feet to try to reduce that risk for neuropathy. So it's it's kind of widely um adapted in infusion centers. Some people buy gloves with ice packs and sometimes the infusion centers will just let the patient wear uh gloves and put their hands in a bucket of ice. So I know that they do that in my infusion center. Some people buy frozen peas and hold their hands on to that. So it's yeah, to reduce the risk of neuropathy in the hands and feet. Excellent. Uh So you mentioned infusion centers um is is, is that where uh patients would, would find access to the cooler ed system or is that um is it something that could be shipped directly to patients or do you have any insight into that? I know that and I I and maybe will let um one of the cooler heads uh people jump on. But my understanding is that right now it's focused in infusion centers. But I do think that in the future, they're, they're always trying to get it to more patients. And initially, I know that they were, their goal was to make it so that individuals could just rent it, especially if their infusion center didn't have uh a device. But um the demand was has been so high. Uh That right now they're focusing on the infusion center so that more people can have access to it. But if anybody from cooler heads wants has any other um pointers on that they can jump on. Um uh Sure. Yeah, they, hey Brandon, I don't know if you can hear me. We can. Yeah. Yeah. So I was just gonna provide a little bit of context to the question. So traditionally, we deal directly with the infusion center and we provide the infusion center with the system with the disposable. All we need is the infusion center to reach out to us and we can orchestrate the system getting to the infusion center with them. And if that does not answer your question by all means, please reach out to one of us and we can give you some detail. Sure, sure. Uh we've had a question come in about um insurance. Is this uh technology did, did is that covered um through most insurance companies or do they cover part of the cost or anything like that? So, um Ryan might have a better answer. I my understanding is that Medicare does cover it and I think it was Aetna. Is it 80%? Is that right, Ryan? Yes. If Medicare does cover for the utility of scalp cooling, all of the private insurers are a bit different and it's across the board on whether or not they cover and how much they cover. So it's, it's independent insurance that kind of dictates those terms. We would anticipate that most private insurers will start to cover considering C MS now does, but that will take a little bit of time as it does with every technology and every platform. You sure, I do have um a, a letter like a standardized template letter that I give out to people uh that they can submit to their insurance for uh extra consideration if they initially decline because there's certain CPT codes you can kind of work with. So other options. OK. Well, so uh speaking as a um a clinician, um uh do your patients or if, if you had had shared your diagnosis with your patients, um do they ask you about uh hair loss? And um since your referral for scalp cooling came from your surgeon, uh ho how is your oncologist with the decision to scalp? Cool. She was fine with it. Um I had a great oncologist. I, I interviewed five cause that's the kind of person I am. And um she, she was one that was always kind of like open if I brought research in or whatever, she, she was like, absolutely. Let's let's do this. Uh The staff was really excited to try cold capping. So it was a really positive experience. Everybody was really, people would come by and, and check in on me when I was cold capping and I had patients I had a mom that we were walking out and, uh, she had seen me and she was asking me about it and I was telling her and she's like, oh, I wish we would have had that for my daughter. We had to do Penguin and it was, you know, the manual and it was just so much. Um, so, yeah, I hopefully answer the question but yeah. Yes. Yes, definitely. Um, and in fact that that also kind of answers some of the other questions that we've had here about your experiences just um as far as like, um could you speak to maybe, um you know, you had mentioned before hair loss. It's both. Oh, it's a mental and physical loss thinking back on that experience. How would you feel that would have been differently if you uh made the decision not to cold cap? Mhm. So, um I just, I didn't even think about not cold capping. I'm just kind of a, I'm a go getter and I'm, I'm like, bring it like, you know, I'm gonna do the max, I can, like I said, I interviewed five oncologists and I, um I'm, I'm just one of those people that I'm gonna try what I can and if it doesn't work out, it doesn't work out. But I have to know in my head that I did everything I could so that I could have the best experience in this terrible situation. Um, for me. So I like, and I think Ryan can attest to it. You know, I, the minute I found out I was gonna have to do chemotherapy, I uh talked to both the infusion centers in my, my town and I said, OK, who wants to be on board with me? Like, I don't want to do manual cold capping, who will partner with me to get machine based coal capping to our town? And I said, I'm, I'm usually a really busy O UN, I'm gonna be off for six weeks from surgery. I'm gonna have nothing to do. Let me be the, let this be my project. Let me uh let there be some stars, some, some silver lining to this thing I'm going through. So, um I contacted both groups, one of the infusion centers said, yeah, let's do this. They got in touch with uh cooler heads and miracles started happening. So I, yeah, once I found that there might be a possibility like I needed some hope to grasp on to. It was like my, I could, I could focus and devote all of my time to it because I did not want to have any extra time to be thinking about breast cancer. I was not sleeping. I wasn't, you know, like I needed something else. So this was just such an amazing opportunity for me for many different reasons. But yeah, once I learned about cold Cine, there was no way I wasn't gonna do it. That's fantastic. Thank you so much. Uh And I'm gonna go ahead and, uh, switch over our slides here. You'll notice, uh, our, um, just another replay of our uh disclaimer here. I wanna go ahead and thank you all uh for taking the time to join us today. Um Doctor Graf, I really appreciate your, um, uh, I really appreciate your time and sharing your experiences with us both as a patient and as a clinician. So, um I, I really can't thank you enough. Absolutely. Thanks for having me. Absolutely. Uh So as we uh come to a close here, I do wanna thank you all once more for joining us today. Uh You'll notice on your screen you can find a full list of our upcoming events uh by visiting us at M MS dot McKesson dot com slash educational dash webinars there. You can register for a future webinar uh share with your colleagues or sign up to receive regular updates on our webinar schedule. Doctor Graf. I'm gonna offer you one more. Thanks for joining us today. I really do appreciate it and you will be able to uh you'll see an email in the next day or so. Uh That will have a link to the recording as well as some information about cooler heads and how to get in touch with those folks. Uh Once again, thank you all for joining us today. I really appreciate it. Have a great day, everybody