Reply to Comments on: "Preventing chemotherapy-induced alopecia: a prospective clinical trial on the efficacy and safety of a scalp cooling system in early breast cancer patients treated with anthracyclines."

We would like to thank you for the interest in our study. The first issue raised by Kako et al. is about the concordance between patients and nurse/physician Dean’s score.

With respect to this issue, we agree that there may be a difference in the subjective assessment of alopecia by patients compared to medical staff. In fact, it is possible that medical staff underestimate the effect of hair loss as it has already been highlighted in the study by Rugo et al. where it was noted that the scores reported by patients are generally lower.[1,2] In the Discussion of our paper,[3] we pointed out that patients who interrupted the scalp cooling system because of unsatisfactory results were 11%. In addition, only 12 patients answered the question in the EORTC-BR23 questionnaire on being upset for the hair loss, showing an increased distress overtime (p < .01). These numbers are too small to draw definitive conclusions.

The second issue is about the relationship between success/failure rate and Dean’s score for the 58 pts who completed the EORTC- QoL questionnaire.

The success rate in these 58 patients was 53% (31/58; 95% CI: 40–67%) and the failure rate was 47% (27/58; 95% CI: 33–60%). The median Dean’s score was 2. The data emerging from this further analysis are in line with the overall results of the study.

We also calculated the mean standardised Body Image (BI) score at baseline and at fourth cycle. At baseline the BI mean score was 77.4 for the success group and 79.2 for the failure group (p = 0.79). At fourth cycle it was 69.4 and 63.2, respectively (p = 0.38 adjusted for BI at baseline). Therefore, both at baseline and at fourth cycle, the difference was not statistically significant.

We are grateful for giving us the opportunity to clarify these issues.