头皮冷却对乳腺癌化疗脱发的作用

　　化疗所致脱发仍是一种令人痛苦的癌症治疗不良事件，但是可以通过头皮冷却进行预防。不过，不同化疗方案的头皮冷却保发（脱发少于50%）成功率不同，紫杉类化疗为41%～59%，蒽环类化疗为16%～36%。虽然头皮冷却具有潜在的实用性，但是对于生活质量的影响尚不明确。

　　2019年2月26日，施普林格·自然旗下《乳腺癌研究与治疗》在线发表美国哈佛大学医学院、麻省总医院、纽约纪念医院斯隆凯特林癌症中心的研究报告，系统回顾了头皮冷却对乳腺癌患者化疗所致脱发和生活质量评分的作用。

　　作者对PubMed、Embase、Web of Science和Cochrane数据库2018年10月29日之前发表的头皮冷却预防化疗所致脱发临床研究进行系统回顾。根据牛津循证医学中心修订的五分制评分，对报告至少5例乳腺癌患者生活质量定量指标的临床研究进行评分。

　　结果，4项随机对照研究、8项队列研究、1项横向研究共计1282例患者符合条件。最常用的生活质量评定指标为欧洲癌症研究治疗组织（EORTC）生活质量问卷（QLQ）核心30项（C30，占46%）和乳腺癌23项（BR23，占46%）。

　　总体而言，13项研究分析了头皮冷却对生活质量指标改善的作用，其中：

• 4项研究（31%）认为改善显著

• 8项研究（62%）认为改善不显著或无

• 1项研究（7.7%）认为改善有些显著、有些不显著或无

　　虽然2项（50%）随机对照研究表明，根据不同的化疗方案，头皮冷却可以不同程度地有效预防化疗所致脱发，但未表明成功保发与生活质量指标改善相关。

　　因此，该研究结果表明，根据EORTC的QLQ-C30和QLQ-BR23评定，头皮冷却并不一致与生活质量显著改善相关。其中关键的局限性在于，超过三分之一的研究未对头皮冷却成功或失败患者的生活质量结局进行亚组分析，而是报告了所有头皮冷却患者的生活质量指标。头皮冷却患者与对照患者相比，预防脱发失败而接受昂贵且潜在不适治疗可能导致幸福感下降，影响生活质量指标总体分布。未来的研究应该加入针对毛发疾病、经过验证的生活质量指标，并且根据保发程度对头皮冷却患者的生活质量结局进行分类。

Breast Cancer Res Treat. 2019 Feb 26.

The effect of scalp cooling on CIA-related quality of life in breast cancer patients: a systematic review.

Dustin H. Marks, Jean-Phillip Okhovat, Dina Hagigeorges, Athena J. Manatis-Lornell, Steven J. Isakoff, Mario E. Lacouture, Maryanne M. Senna.

Massachusetts General Hospital, Boston, USA; Harvard Medical School, Boston, USA; Memorial Sloan Kettering Cancer Center, New York, USA.

PURPOSE: Chemotherapy-induced alopecia (CIA) remains a distressing adverse event of cancer treatment but may be prevented by scalp cooling. The effectiveness of scalp cooling, however, is dependent on the chemotherapy regimen with successful hair preservation (i.e., <50% hair loss) in 41-59% of women on taxane-based therapies in comparison to 16-36% on anthracycline-based therapies. Despite the potential utility, use of scalp cooling has shown a more equivocal impact on quality of life (QoL). In this review, we aim to evaluate the use of scalp cooling for CIA and quantitative QoL measures.

METHODS: A systematic review of PubMed, Embase, Web of Science, and Cochrane databases for clinical studies on scalp cooling to prevent CIA published before October 29, 2018 was performed. Clinical studies with 5 or more patients that reported on a quantitative QoL measure were included and graded according to a modified five-point scale from the Oxford Centre for Evidence-Based Medicine.

RESULTS: Studies meeting inclusion criteria included 4 randomized clinical trials (RCT), 8 cohort studies, and 1 cross-sectional study with 1282 unique patients. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (QLQ-C30: 46%) and Breast Cancer Module (QLQ-BR23: 46%) represented the most commonly used QoL assessments. Overall, 4 (31%) of the 13 studies concluded that scalp cooling was associated with significant improvements in QoL measures; 8 (62%) determined that there was either non-significant or no improvements; and 1 (7.7%) provided a mixed conclusion. Although 2 (50%) RCT demonstrated that scalp cooling can effectively prevent CIA depending on the chemotherapy regimen, these studies did not show that successful hair preservation was associated with improved QoL measures.

CONCLUSIONS: This review demonstrates that scalp cooling is not consistently associated with significant QoL improvements as assessed by EORTC QLQ-C30 and -BR23. Representing a critical limitation, more than one-third of the studies did not subcategorize QoL outcomes for successfully or unsuccessfully scalp-cooled patients but rather reported on QoL measures for all scalp-cooled patients in general. Failure to prevent hair loss in patients undergoing an expensive and potentially uncomfortable treatment likely contributes to decreased well-being, impacting the overall distribution of QoL measures in scalp cooling patients compared to controls. Future studies should incorporate validated QoL instruments specific to hair disease and classify QoL outcomes for scalp-cooled patients based on the degree of hair preservation.

KEYWORDS: Scalp cooling Scalp hypothermia Chemotherapy-induced alopecia Quality of life QLQ-C30, QLQ-BR23

DOI: 10.1007/s10549-019-05169-0

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