Barriers Prevent Scalp Cooling Use in Black Patients With Breast Cancer

Black women with breast cancer face a convergence of financial, informational, and structural barriers that drive dramatically lower rates of scalp cooling (SC) use to prevent chemotherapy-induced alopecia (CIA) compared with their White counterparts, according to a qualitative, semistructured interview study published in Supportive Care in Cancer.¹

The study was motivated by the results of an earlier study from some of the same researchers that found that non-White patients with breast cancer were approximately 6 times less likely to use SC than White patients (OR 0.15; 95% CI, 0.03-0.63).²

“Given that Black patients are more likely to be treated with systemic chemotherapy due to advanced disease or aggressive biology, the burden of near-universal adverse hair loss is of interest in this patient population,” the authors explained.¹

How This Fits Into the Broader Landscape

While Black women are more likely to experience CIA due to the treatment they receive, the tools designed to prevent and measure that burden have largely been developed and validated in populations with nontextured hair types.

For Black women, whose hair may be culturally significant, addressing and preventing hair loss is important. Some women may actually decline chemotherapy or lifesaving treatment because of the prospect of losing their hair, even temporarily, Crystal Aguh, MD, FAAD, Johns Hopkins School of Medicine faculty, told The American Journal of Managed Care^®.³

“I find that within the African American community, in the African diaspora, broadly speaking, hair is super important,” she said. “It's not just another body part; a lot of women refer to it as their crown. When you lose that crown, it can feel like you've lost a lot of your femininity.”

What the Interviews Revealed

Researchers conducted 1-hour semistructured Zoom interviews with 17 Black women (mean age 50.16 years) who had received chemotherapy for breast cancer at the Ohio State University Comprehensive Cancer Center between 2018 and 2022. Three major domains emerged: the impact of hair loss, barriers to SC use, and strategies for improving CIA management.

Of the 17 participants, 10 did not use SC. The most prominent barrier was the near-total absence of Black women in SC-related advertising and manufacturer materials. Patients reported turning to manufacturer websites, brochures, and YouTube videos to research the treatment after oncology discussions, only to find little representation of women who looked like them. One patient said the lack of presentation made her feel they didn’t have “total understanding of true Black women with my hair.”

Concern about SC efficacy in textured and coily hair was the second major theme. Patients reported uncertainty about whether the cooling cap would fit securely over natural hair after wetting, and several described self-directed modifications—cutting hair into a pixie style, applying generous amounts of gel, or using an alternative leave-in conditioner—to try to improve cap-to-scalp contact. For those who did complete SC, approximately 57% reported satisfaction with their results.

Cost was an equally significant deterrent. SC expenses range from roughly $1347 to $2245, and while insurance coverage is improving, many patients still face out-of-pocket costs. Several participants in this cohort reported declining SC based on cost alone, with one saying that the out-of-pocket expense seemed too high given the uncertainty of whether her hair could be saved.

Where the Evidence Falls Short

The study was conducted at a single institution, which limits the generalizability of its findings. Participation was voluntary, raising the possibility of selection bias, and the retrospective assessment of attitudes introduced the potential for recall bias.

Addressing the Barriers to Scalp Cooling

Improving access to CIA prevention and management for Black patients will require changes at multiple levels, the authors concluded. On the clinical side, they recommend a "texture-tailored" counseling approach that accounts for patients' baseline styling practices, including whether their hair is natural or chemically relaxed, before recommending SC protocols. Oncologists should also consider early dermatology referrals and proactively inform patients about financial assistance programs from nonprofit organizations, which patients in this cohort were largely unaware of.

Better access to racially inclusive wigs that are similar in texture or style to their natural hair is also needed to improve CIA management for this population. One patient said the wigs looked fake because they didn’t look like a Black person’s hair.

Finally, improved insurance coverage or financial assistance can help with CIA counseling. Not only would coverage of SC help, but also for the “reconstruction phase,” such as hair retention, camouflage, and regrowth.

“Interdisciplinary collaboration among oncologists, dermatologists, wig boutiques, and hairdressers could provide an optimal, patient-centered strategy,” the authors concluded.

References

1. Minta A, Rose L, Ueltschi O, et al. An interview-based qualitative study of scalp cooling, alopecia, and disparities in Black breast cancer patients. Support Care Cancer. 2026;34:498. doi:10.1007/s00520-026-10721-y

2. Rose L, Schnell PM, Radcliff L, Lustberg M, Dulmage B. Retrospective cohort study of scalp cooling in breast cancer patients. Support Care Cancer. 2023;31(2):118. doi:10.1007/s00520-022-07562-w

3. Santoro C, Aguh C. Dermatologists advocating for inclusive hair loss research and treatment in the African diaspora. AJMC. March 26, 2025. Accessed May 15, 2026. https://www.ajmc.com/view/dermatologists-advocating-for-inclusive-hair-loss-research-and-treatment-in-the-african-diaspora