Manual Scalp Cooling in Early Stage Breast Cancer: Value of Caretaker Training and Patient-Reported Experience to Optimize Efficacy and Patient Selection

Title: Manual scalp cooling in early stage breast cancer: value of caretaker training and patient-reported experience to optimize efficacy and patient selection Authors: Manaz Rezayee1, BS Nicole Moxon1, RN Staci Mellinger1, RN Amanda Y. Seino1 Nicole E. Fredrich1 Tracy L. Kelly1 Susan Mulligan2, MA Patrick Rossi3, MD Ijeoma Uche1, MD Walter J. Urba1, MD PHD Alison K. Conlin1, MD MPH Janet Ruzich1, DO David B. Page1, MD Background: Alopecia is an emotionally distressing common adverse effect of curative-intent chemotherapy in early stage breast cancer.1–6 Although machine-based scalp cooling is effective for reduction of chemotherapy-associated alopecia in early stage breast cancer, availability is geographically limited.7–11 Manual cold-cap systems may also be effective and are available regardless of geographic location.12–14 We evaluated the feasibility of caretaker-administered cold-cap efficacy following structured standardized training, and utilized patient-reported subjective outcomes to develop a clinical tool to facilitate patient selection. Patients and Methods: A small pilot study (n=10) was conducted to evaluate the feasibility and efficacy of manual cold capping. Key eligibility criteria included: 1) no hair loss at baseline; 2) no pre-existing scalp condition; 3) planned curative-intent chemotherapy for early stage breast cancer and 4) availability of caretaker(s). Participants received standardized training and then performed the cold-cap procedure without assistance. The primary endpoint was post-treatment hair retention using Dean’s alopecia scale, with success defined as Results: Of the evaluable patients, 80% (n=8/10) met the primary efficacy endpoint (Dean’s scale 0-2) with 20% (n=2/10) trial failures due to pre-mature discontinuation. Manual cold-capping was worthwhile to 90% of patients (Was it Worth It? Questionnaire) and associated with favorable PROs. Patient interviews identified a number of themes shared by almost all patients, which were subsequently used to develop a questionnaire to aid patient-directed decision-making on whether to pursue manual cold-capping. Conclusion: This study affirms the safety and efficacy of manual cold-capping to reduce alopecia and demonstrates the importance of proper training and education to maximize efficacy. It also highlights the considerable costs and effort associated with cold-capping. Selected patients with early stage breast cancer may benefit subjectively from cold capping while the proposed clinical instrument can be used to facilitate an informed discussion between patient and provider.https://digitalcommons.psjhealth.org/cancer_institute_fellowships/1000/thumbnail.jp

NORSE and Super-Refractory Status Epilepticus: a Single-Center Retrospective Chart Review

Rationale: New-Onset Refractory Status Epilepticus (NORSE) is a rare life-threatening condition in previously healthy patients who develop new-onset medically-refractory status epilepticus of unclear etiology.1NORSE commonly leads to super-refractory status epilepticus (SRSE), a severe form of status epilepticus for which seizures persist despite 24 hours of adequate anti-seizure and anesthetic treatment. The goal of this study is to examine the clinical characteristics and epidemiology of super-refractory NORSE, a subset of SRSE, to determine risk and prognostic factors associated with this rare condition, and mortality rates. Methods: We performed a retrospective cohort study of all cases of SRSE admitted to Oregon Health & Science University, an academic tertiary care center between 2007 and 2016. Results: Among 358 patients monitored on continuous EEG for at least 4 days in a single admission, 67 (19%) were identified as having SRSE. In-hospital mortality for SRSE (all causes) was 30% (20), but for the specific NORSE group 15% (2), for pre-existing epilepsy 40% (4) and for symptomatic 32% (14). Conclusions: The results of this study are consistent with prior reports of NORSE epidemiology: the condition is rare, patients tend to be younger, female-predominate, and there have been no antibodies clearly-associated with the condition. A novel finding in this study was that 50% of NORSE cases had positive antibody testing– the majority of which were thyroid-associated antibodies (41.7%). Based on a population-based study at baseline of 5783 participants, 12.8% were positive for TPO antibodies with a higher prevalence in women compared to men.2 While thyroid-associated antibodies are thought to be non-specific markers of inflammation and/or autoimmunity, this supports the hypothesis that NORSE (or a subset of NORSE cases) may be autoimmune-mediated and establishes a potential autoimmune link