The Case of the Cryotherapy Consequences
Janice is 32 years old and was recently diagnosed with triple-negative breast cancer. She is receiving neoadjuvant chemotherapy with doxorubicin and cyclophosphamide, followed by weekly paclitaxel. Janice is a nationally recognized performer (vocal and piano) and is distraught over the possibility of losing her hair or developing chemotherapy-induced peripheral neuropathy (CIPN) and mouth sores. She asks the nurse what can be done to prevent those unwanted side effects.
What Would You Do?
Cryotherapy—the use of cold temperatures to promote vasoconstriction, thereby reducing the cytotoxic effect of chemotherapy to the cooled body part—has been studied for its effectiveness in reducing the risk for oral mucositis (OM), hair loss, ocular toxicity, and CIPN (https://doi.org/10.1016/j.jpainsymman.2013.07.014). Early evidence from multiple studies showed that oral application of, or sucking on, ice chips during chemotherapy infusion reduced the incidence and duration of OM by close to 50% when compared with no cryotherapy. Additionally, the majority of studies Kadakia et al. (https://doi.org/10.1016/j.jpainsymman.2013.07.014) reviewed demonstrated that cryotherapy reduced the incidence of ocular toxicity from 5-fluorouracil. As scalp cooling technologies have evolved, evidence supports use of cryotherapy to prevent hair loss (https://doi.org/10.3389/fonc.2019.00733). Cryocompression, the use of cold therapy and compression, is also being studied with CIPN; thus far, results have been favorable, but more research is necessary (https://doi.org/10.1188/17.CJON.226-233).
Evidence, however, is lacking regarding how many parts of the body can be safely cooled simultaneously. A clinical trial evaluating concomitant limb cryocompression and scalp cryotherapy is slated to be completed in April 2020 (http://clinicaltrials.gov/ct2/show/NCT03248193), but until the results are published, clinicians have little guidance on how to advise patients who want to cool multiple body parts during chemotherapy infusions.
The clinic nurse discusses the strength of evidence related to cryotherapy and CIPN, OM, and hair loss. She also tells Janice that studies are still being conducted regarding cooling multiple areas of the body at once. Ultimately, Janice decides to try scalp, limb, and mouth cryotherapy but abandons the scalp cooling because of headaches and overall cold intolerance. She did not develop CIPN or mouth sores during treatment.