Managing and preventing breast cancer side effects a focus of 2023 ASCO meeting | ASCO 2023

That shift in focus was evident at the 2023 meeting of the American Society of Clinical Oncology, as doctors shared results of research designed to find better ways to prevent and manage the side effects of cancer treatment. In a dedicated session, oncologists from leading cancer centers shared updates on integrative medicine and approaches to prevent peripheral neuropathy and hair loss and to reduce pain.

Managing peripheral neuropathy

Peripheral neuropathy is one of the most common side effects of chemotherapy. It causes pain, tingling, and numbness in the hands and feet. As many as 68% of people who receive taxane-based medications develop peripheral neuropathy. The drug duloxetine (Cymbalta) can ease pain caused by peripheral neuropathy, but it doesn’t help with numbness or tingling. Many people don’t want to take yet another pill with limited benefit.

Recognizing this challenge, doctors continue to explore non-medical options such as compression therapy and cryotherapy. Compression therapy involves tightening or constricting potentially affected areas. Cryotherapy applies freezing temperatures. Both use special gloves or socks to narrow the blood vessels, preventing cancer drugs from reaching the hands and feet.

Research on both approaches is promising but inconclusive. Cryotherapy itself brings risk of discomfort. In more than one study, one-third of people who were in the cryotherapy study group discontinued treatment. In a comparison study, compression outperformed both cryotherapy and a placebo (a nonactive treatment).

New studies look at cryocompression, a combined approach that lowers the skin temperature with less discomfort. The ICE COMPRESS clinical trial will compare cyrocompression to continuous compression and low-cycle compression to prevent peripheral neuropathy. The trial just enrolled its first participant.

Scalp cooling for hair loss

Some of the same principles behind compression and cryotherapy apply to scalp cooling, used to prevent or lessen hair loss from chemotherapy. Around half of people treated for breast cancer consider hair loss one the most traumatic parts of treatment, and some decline chemotherapy for fear of hair loss.

The FDA has approved the DigniCap and PAXMAN scalp cooling systems to prevent hair loss. These approvals were based mostly on data in early-stage breast cancer trials of white people receiving taxane-based chemotherapy. Limited evidence exists for those with metastatic breast cancer, people receiving antibody-drug conjugates, and people of color, particularly Black people.

Scalp cooling introduces a very cold temperature to the scalp for a set time before, during, and after treatment. Dose, cooling schedule, and cap fit are critical for success. Cold caps offer flexibility in that post-cooling can be done anywhere, but they can be more cumbersome to use, often requiring a helper. The DigniCap and PAXMAN machines require less work by users but people must remain connected to the machine during the post-cooling time.

Scalp cooling is both safe and effective but can be costly and does not work for everyone. A 2017 trial found that PAXMAN prevented hair loss in 59% of people taking taxane drugs but in only 16% of those receiving anthracycline-based chemotherapy. Another study of PAXMAN in Black people with breast cancer closed early due to concerns about the treatment causing hair loss.

Cost is also a barrier to wider use. Scalp cooling can cost $1,500 to $3,000 per person, an expense often not covered by insurance. Medicare has started to cover it, and nonprofit support can offset costs for some.

A new clinical trial at Dana-Farber Cancer Institute in Boston will test scalp cooling in people with metastatic breast cancer receiving sacituzumab govitecan (Trodelvy), trastuzumab deruxtecan (Enhertu), or eribulin (Halaven). The patient-centered trial allows participants to choose to try scalp cooling or not and aims to recruit a racially diverse study group. A small study in Montefiore Medical Center in New York looks exclusively at scalp cooling for Black and Hispanic people.

Medical marijuana for side effects

Medical cannabis–and its active ingredients THC and CBD—is also of great interest to people with cancer. In a national survey, 80% of oncologists reported discussing cannabis with patients and nearly half had recommended it. A 2017 review of the research supports the use of cannabis for chemotherapy-induced nausea and vomiting. In contrast, a 2022 study showed no difference between CBD and a placebo (an inactive substance) for symptom burden caused by advanced cancer. Research on medical cannabis moves slowly in the United States due to legal restrictions.

Dr. Richard Lee, an oncologist and palliative care specialist who conducts cannabis research, believes that people often consider medical marijuana too early, overlooking FDA-approved treatments with stronger evidence. To people who are very interested in cannabis, he recommends dronabinol (Marinol), an FDA-approved, THC-based drug for nausea and vomiting. This fall, Dr. Lee will begin enrolling participants in a new California-based clinical trial to evaluate CBD for peripheral neuropathy in people with breast and colon cancers.

The power of patient voice is evident across these and other trials that address side effects. In response to advocacy, established medical groups increasingly recognize the potential of treatments like cannabis that fall under the umbrella of integrative medicine. The NCCN now recommends acupuncture, relaxation therapy, and mindfulness for pain. The American Society of Clinical Oncology and the Society for Integrative Oncology jointly support the use of acupuncture for AI-related joint pain in breast cancer and massage for chronic pain caused by breast cancer treatment.

Learn more about clinical trials to prevent and manage side effects at clinicaltrials.gov.