Controversies in treatment-induced alopecia and hair adverse events were brought to the attention of the medical community in a presentation by Mario Lacouture, MD, at the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology 2014 annual meeting.
The controversies lie in the prevention and treatment of alopecia. “Hair adverse events are frequent with anticancer therapies,” said Lacouture, a dermatologist at Memorial Sloan Kettering Cancer Center in New York City, specializing in conditions that result from cancer treatments. “Patient counseling is critical so that doctors can make recommendations and assess the impact of these events on quality of life.”
In alopecia due to cytotoxic chemotherapy, there is a reduction in the number of cells that make hair, resulting in hair loss; inhibited growth; weak, brittle, and constricted hair shafts subject to breakage; and a reduction in diameter of the hair shaft.
Typically, people who lose a lot of hair lose it very fast; people who lose hair slowly have a longer recovery. “This may be important for counseling of patients as well as for understanding the mechanisms of toxicity,” Lacouture said.
The Psychosocial Implications
The psychosocial ramifications of chemotherapy-induced alopecia must not be underestimated. Alopecia is the most traumatic effect of chemotherapy, according to 47% of breast cancer patients surveyed, 8% of whom said they would reject chemotherapy because of alopecia alone. Some women report that losing a breast due to a mastectomy would be less traumatic than losing all of their hair, Lacouture noted.
Additionally, there is a gender difference in terms of the psychosocial impact of hair loss. Women are much more concerned about scalp alopecia, whereas men tend to be more concerned about body alopecia.
Children undergoing cytotoxic chemotherapy tend to suffer social isolation as a result of alopecia, while people older than 60 years tend to be more affected by its psychosocial impact. Additionally, there is the issue of stigma; everyone knows the patient is receiving chemotherapy, which results in a feeling of loss of privacy.
The relative impact of alopecia depends on tumor type and stage. It is the second most important toxicity in breast and lung cancers, whereas it is not even in the top 10 in gastrointestinal cancers or stage 4 disease.
Chemotherapy-induced alopecia is graded by the Common Terminology Criteria for Adverse Events, but other grading systems have been implemented in the past few years, primarily led by Elise Olsen, MD, at Duke University Medical Center in Durham, North Carolina, one of the world’s leading hair experts. She has devised a grading system in which a person has to lose more than 50% of his or her hair in order for other people to notice. “This is reassuring to patients,” said Lacouture. “It also helps us to understand the severity of hair loss.”
There is a lesser severity of alopecia with the use of targeted therapies. It is important to keep in mind, though, that patients exposed to epidermal growth factor receptor (EGFR) inhibitors develop a myriad of skin toxicities and infections. Therefore, alopecia is not only a mechanism-based effect; it can also be a consequence of infection. Patients can present with alopecia that is actually an infection on the scalp, Lacouture explained.
“The problem with this and what makes patients very upset,” he said, “is that once these patients have an infection on the scalp, it leads to a scar. And when there is a scar on the scalp the hair is never going to grow back there again. This is a very undertreated problem.”
Patients on EGFR inhibitors who develop crust on their scalp should have the areas cultured; these patients are likely to have an infection that will need oral antibiotics, Lacouture advised.
Persistent Alopecia and Its Consequences
“I’ve never seen patients as upset as those on cytotoxic agents whose hair never fully grows back, because these people were never told that this could happen,” said Lacouture.
The incidence of persistent alopecia is unknown, but one group significantly affected is children who receive chemotherapy. In an analysis of over 40,000 patients from the Childhood Cancer Survivor Study, about 40% of children experienced persistent hair loss, which led to a higher risk of depression and anxiety when they became adults. “This is important for us to know since childhood cancer survivors are living longer and longer,” stated Lacouture.
“I favor the term ‘persistent’ because that connotes that there is something that can be done. If you see a patient and you tell them they have ‘permanent’ chemotherapy-induced alopecia, that means there is probably nothing that can be done. I don’t think we know yet that there is nothing that can be done, and the histology does not support the notion that there is nothing that can be done,” he said.
It is important to evaluate chemotherapy-induced alopecia at baseline and again every 3 months with standardized photos, trichoscopies, and, in some cases when inflammation or infection is suspected, with scalp biopsies. This allows for careful quantification, as patients who rely on memory can be very disappointed by their hair regrowth.
Monitoring, Treatment, and Counseling—What Can Be Done?
Lacouture and his colleagues have found that for EGFR inhibitor–induced toxicities and the prevention and management of alopecia, over-the-counter minoxidil is effective for regrowth of eyebrows, as is prescription bimatoprost for eyelashes. Camouflaging hair powders, thickeners, and wigs are also recommended.
In observational and autopsy studies, scalp cooling has been shown to be safe and cost-effective for alopecia prevention. According to some studies, in patients who develop complete alopecia, shaving the head is less traumatic than seeing clumps of hair falling out. Additionally, in anecdotal studies, about 65% of patients report changes in density, color, or structure of their hair after it has been lost and recovered. It is important to keep this in mind when counseling patients prior to the start of chemotherapy, Lacouture advised.
Chemotherapy-induced alopecia reminds patients of their disease, negatively affects social interactions, and can lead to decreased self-esteem, sexuality, and sensuality. Therefore, patient counseling is critical. “Women ask frequently, ‘Am I going to lose my eyebrows and my eyelashes?’ ” added Lacouture. “The best answer we have for them is ‘Maybe.’ We want to have numbers.”
Lacouture ME. Controversies in chemotherapy and endocrine agent-induced alopecia [meet the expert]. Presented at: 2014 Annual Meeting of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology; June 26-28, 2014; Miami, FL.