Preventing and Managing Alopecia in Breast Cancer Patients

Mario E. Lacouture, MD

Topical minoxidil can be of significant benefit to women with breast cancer who develop alopecia during treatment with endocrine therapies, our most recent research shows.

In the study, published in JAMA Dermatology, (1)) we identified alopecia with a similar pattern to the androgenetic type - partial hair loss that is more prominent on the front and vertex of the scalp. Using standardized clinical photographs, we found that 80 percent of women (37 of 46) with endocrine therapy–induced alopecia who were treated with topical minoxidil 5 percent showed a moderate to significant improvement. (1)The research was conducted in collaboration with colleagues at the New York University School of Medicine and Weill Cornell Medicine.

To date, the significant negative emotional impact of alopecia on the quality of life of people with cancer and cancer survivors has not been receiving the attention it deserves. To help address this gap, MSK’s dermatology and breast cancer experts collaborated with colleagues at other centers and recently published two continuing medical education articles in the Journal of the American Academy of Dermatology. We reviewed clinically significant hair-related disorders, underlying pathophysical mechanisms, severity grading scales, patient-reported quality-of-life instruments, management strategies, and future translational research opportunities.

At MSK, the overall goal is to foster a better understanding of dermatologic adverse events so that people with cancer can receive adequate support today and benefit from preventive therapies in the future. This clinical update provides an overview of the incidence and impact of alopecia, a review of current management strategies, and a synopsis of promising research currently under way.

The Incidence and Impact of Alopecia

As cancer survival rates increase, a growing number of cancer survivors are affected by persistent or permanent hair disorders. Chemotherapy-induced alopecia is the most common, occurring in about 65 percent of people who are treated for cancer. (2) However, alopecia is also associated with radiotherapy, targeted therapies, immunotherapies, stem cell transplants, and endocrine agents. (3) The incidence of alopecia varies by treatment, occurring in almost every patient receiving radiotherapy to areas of the head, 15 percent of those receiving targeted therapies, and 1 to 2 percent of those treated with immune checkpoint inhibitors. (3)

To date, the significant negative emotional impact of alopecia on the quality of life of people with cancer and cancer survivors has not been receiving the attention it deserves
Mario E. Lacouture Director, Oncodermatology Program; Research Director, Dermatology Service

For many people, particularly women, facing cancer treatment alopecia is the most disturbing anticipated adverse event and causes high psychological distress. (4), (5)In previously published studies, 17 percent of women with gynecologic cancers said that alopecia was the most traumatic adverse event during their treatment, 30 percent reported they were severely limited by it, and up to 14 percent said they would consider rejecting curative therapies associated with alopecia. (6), (7), (2)In our most recent study among women with breast cancer who had endocrine therapy–induced alopecia, we were surprised that our patients reported a significant negative emotional impact though most had mild hair loss. (1)Finally, other researchers have confirmed that persistent or permanent alopecia after cancer treatment is associated with depression, anxiety, and increased somatization. (8)

Alopecia Management Strategies

Results with topical minoxidil to date are encouraging but not definitive. Our most recent study found a moderate to significant improvement in 37 of 46 people with breast cancer who had endocrine therapy–induced alopecia and were treated with topical minoxidil 5 percent. (1) In another study, a randomized trial of 22 people with breast cancer who received cytotoxic chemotherapy, treatment with topical minoxidil 2 percent reduced the duration of alopecia by 50 days compared with placebo. (9)Taken together, these results are promising, but more research in larger groups of participants is needed to demonstrate the satisfactory efficacy of topical minoxidil and justify its widespread use.

Scalp cooling is the most widely used method for preventing chemotherapy-induced alopecia. Studies have shown that the technique can prevent grade 2 alopecia (more than 50 percent hair loss) in 51 to 67 percent of people. (10), (11)The plausible mechanism of action is that cooling reduces the scalp’s blood flow by about 20 percent, decreasing the uptake of cytotoxic therapies by the hair follicles. (3)Hair preservation rates vary by chemotherapy regimen, with people receiving taxane treatments showing a higher preventive benefit. (3)Unfortunately, there is no long-term data available on the efficacy of scalp cooling to prevent persistent chemotherapy-induced alopecia, (7)and it has not demonstrated effectiveness in preventing radiotherapy-induced alopecia. (12) A further concern is that scalp-cooling systems are not reimbursable by insurance companies. People may be able to obtain financial assistance through Hair to Stay and Cold Capital Fund. Counseling regarding the possibility of developing persistent or permanent alopecia with anticancer therapies is essential so that people with cancer can minimize the negative impact on their quality of life.

Current Research

Several preclinical interventions have been tried for chemotherapy-induced and radiotherapy-induced alopecia, but only a few have demonstrated clinical benefit. We presented the final data from our recent phase I study of topical calcitriol (BPM 31543) for the prevention of chemotherapy-induced alopecia at the American Society of Clinical Oncology’s annual meeting in 2017. The data showed that twice daily application of BPM 31543 in people receiving taxane-based chemotherapy was well tolerated and safe, with no maximum tolerable dose detected. We noted efficacy at each dose level. (13) Researchers in Korea are investigating a topical botanical blend solution to see whether it can prevent permanent chemotherapy-induced alopecia in breast cancer survivors. (14)

With Shari B. Goldfarb from the Breast Medicine Service, our ongoing CHANCE Study (A Prospective, Longitudinal Study of Chemotherapy-Induced Hair Changes and Alopecia, Skin Aging and Nail Changes in Women with Non-Metastatic Breast Cancer) examines the incidence, risk factors, psychosocial impact, genetic markers, and clinical features of persistent chemotherapy-induced alopecia and endocrine therapy–induced alopecia in 500 breast cancer survivors. The target study completion date is August 2018. We anticipate that the findings will yield critical insights for identifying preventive and reactive treatment strategies to help more people in the future. Similar studies in those with other cancers are urgently needed.

At Memorial Sloan Kettering Cancer Center, the Oncodermatology Program in the Dermatology Service is an interdisciplinary effort that provides people with pretreatment counseling and preventive care for dermatologic events. The program’s goal is to help minimize the occurrence and impact of adverse dermatologic events due to cancer therapies and help ensure the best dermatology-related quality of life for the people we care for.

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  1. Freites-Martinez A, Shapiro J, Chan D, et al. Endocrine therapy–induced alopecia in patients with breast cancer. JAMA Dermatol. Published online April 11, 2018.
  2. Hackbarth M, Haas N, Fotopoulou C, et al. Chemotherapy-induced dermatological toxicity: frequencies and impact on quality of life in women’s cancers. Results of a prospective study. Support Care Cancer. 2008;16:267-73.
  3. Freites-Martinez A, Shapiro J, Goldfarb S, et al. CME part 1: hair disorders in cancer patients. J Am Acad Dermatol. In press, available online April 14, 2018.
  4. McGarvey EL, Baum LD, Pinkerton RC, Rogers LM. Psychological sequelae and alopecia among women with cancer. Cancer Pract. 2001;9:283-9.
  5. Choi EK, Kim IR, Chang O, et al. Impact of chemotherapy-induced alopecia distress on body image, psychosocial well-being, and depression in breast cancer patients. Psychooncology. 2014;23(10):1103-10.
  6. Gandhi M, Oishi K, Zubal B, Lacouture ME. Unanticipated toxicities from anticancer therapies: survivors’ perspectives. Support Care Cancer. 2010;18:1461-8.
  7. Bezjak A, Tu D, Bacon M, Osoba D, Zee B, Stuart G, et al. Quality of life in ovarian cancer patients: comparison of paclitaxel plus cisplatin, with cyclophosphamide plus cisplatin in a randomized study. J Clin Oncol. 2004;22:4595-603.
  8. Freites-Martinez A, Shapiro J, van den Hurk C, et al. CME part 2: hair disorders in cancer survivors. J Am Acad Dermatol. In press, available online April 14, 2018.
  9. Duvic M, Lemak NA, Valero V, et al. A randomized trial of minoxidil in chemotherapy-induced alopecia. J Am Acad Dermatol. 1996;35:74-8.
  10. Nangia J, Wang T, Osborne C, et al. Effect of a scalp cooling device on alopecia in women undergoing chemotherapy for breast cancer: the SCALP randomized clinical trial. JAMA. 2017;317:596-605.
  11. Rugo HS, Melin SA , Voigt J. Scalp cooling with adjuvant/neoadjuvant chemotherapy for breast cancer and the risk of scalp metastases: systematic review and meta-analysis. Breast Cancer Res Treat. 2017;163:199-205.
  12. Van den Hurk C, de Beer F, Dries W, et al. No prevention of radiotherapy-induced alopecia by scalp cooling. Radiother Oncol. 2015;117(1):193-4.
  13. Lacouture ME, Konner JA, Belum VR, et al. A phase I safety study of topical calcitriol (BPM 31543) for the prevention of chemotherapy-induced alopecia (CIA). J Clin Oncol. 2017;35:15 suppl, e14064-314064.
  14. Evaluation of the Impact of a Topical Lotion on Permanent Chemotherapy Induced Hair Disorders in Cancer Survivors (VOLUME).