Helping Cancer Patients Through the Trauma of Hair Loss

Kate M. O'Rourke


December 01, 2017

If you visit breast cancer discussion forums, you will find them peppered with concerns from women about losing their hair after starting hormonal therapy with an aromatase inhibitor (AI) or tamoxifen.[1] Endocrine therapy-induced alopecia (EIA) is a common and underappreciated problem in the care of women with breast cancer, including metastatic disease.[2,3,4]

On a discussion board on, one woman writes that she is devastated by her thinning hair and believes her oncology team is brushing her concerns aside in a "what are you moaning about, small price to pay kind of way." But for many women, it is not a small price.

Significant Impact of Hair Loss From Endocrine Therapy

According to Mario Lacouture, MD, director of the Oncodermatology Program at Memorial Sloan Kettering Cancer Center in New York City and an authority on hair loss in cancer patients, EIA can have a significant impact on patients' emotional well-being and adherence to treatment for breast cancer. Surveys show that two thirds of women view alopecia as one of the most traumatic events that occur during breast cancer treatment, and 8% of women say they would reject treatment because of alopecia alone.[5]

Two thirds of women view alopecia as one of the most traumatic events that occur during breast cancer treatment.

Alopecia in women can spark dissatisfaction with one's appearance, depression, anxiety, obsession, and low self-esteem.[5,6] Many patients experience significant disturbance in their social life, such as avoiding social meetings.[5,6] In one survey of women with alopecia, 40% said that hair loss had caused marital problems and 63% said it had adverse career-related issues.[6] Psychological morbidity can occur with equal frequency in women whose hair is typically covered by a headscarf.[7]

EIA has a different clinical presentation from that of chemotherapy-induced alopecia. EIA is usually milder in severity, tends to be localized at the frontal hairline, and usually responds to topical minoxidil, said Dr Lacouture. At the 2017 annual meeting of the Multinational Association of Supportive Care in Cancer, Dr Lacouture highlighted unpublished data involving 41 patients with EIA who were treated with Minoxidil, of whom 75% had moderate to significant improvement. Minoxidil 5% foam daily is the only therapy approved by the US Food and Drug Administration for female pattern hair loss, and it has been shown to have varying degrees of effectiveness in patients with EIA.[4,8]

According to Rochelle Torgerson, MD, PhD, a dermatologist at the Mayo Clinic in Rochester, Minnesota, hair loss from endocrine therapy can be classified as a telogen effluvium. "It [EIA] really doesn't deserve its own name. It is a telogen effluvium," Dr Torgerson told Medscape. Telogen effluvium, which results in thinning or shedding of hair, occurs when a large number of hairs in the growing phase of the hair cycle abruptly enter the resting phase, triggered by metabolic stress, hormonal changes, or medication.[9]

Dr Torgerson said that most telogen effluvium is not permanent and will stop when therapy stops. "Most telogen effluvium will reset to the normal amount of shedding for that person, and hair will return to the density that they recall," explained Dr Torgerson.

Pretherapy Counseling

Pretherapy counseling about potential hair loss from endocrine treatment is important. "We inform patients [on endocrine therapies] that between 4% and 30% of patients can experience some hair loss, which is not complete, and may appear up to 2 years after starting therapy," said Dr Lacouture.

Many studies have tried to shed light on the incidence of EIA. Although hair loss in women can occur naturally with age or for other reasons, use of an AI quadruples the chances of new-onset hair loss in women, according to a prospective study comparing 146 women with breast cancer initiating AI therapy with 144 postmenopausal women without a history of cancer.[10] In another study of 851 female breast cancer survivors, 22.4% reported hair loss and 32% reported hair thinning; those who were within 2 years of starting AI treatment were approximately 2.5 times more likely to report hair loss (odds ratio [OR], 2.55).[2] AI use for 2 or more years was associated with hair thinning (current users, ≥ 2 years: OR, 1.86; prior users: OR, 1.62), but not hair loss.

Alopecia is more common with selective estrogen receptor modulators, such as tamoxifen, than with AIs, such as anastrozole, exemestane, and letrozole (Femara®).In a meta-analysis of 35 phase 2/3 clinical trials involving 13,415 patients with breast cancer who were receiving endocrine therapy, the incidence of any grade alopecia for AIs and fulvestrant (Faslodex®) hovered around 2.5% and was 9.3% for tamoxifen.[5] Grade 2 or greater alopecia was reported in patients receiving exemestane (1.3%), letrozole (0.2%), and tamoxifen (6.4%). Notably, the majority of the trials in the analysis did not collect data on alopecia.

Most hair loss experienced by patients on hormone therapy falls into the grade 1 category, characterized as hair loss of less than 50% of normal for that individual that is obvious upon inspection, but not obvious from a distance.[11] Patients with grade 1 alopecia may be able to cover their hair loss with a different hairstyle, but would not require a wig or hairpiece. Grade 2 alopecia is hair loss of more than 50% of normal for that individual that is readily apparent to others and would require a wig or hairpiece for the loss to be completely camouflaged.[11] In a chart review of 74 patients referred to the dermatology service for alopecia that developed during endocrine therapy, 93.2% was grade 1 in severity and 6.8% was grade 2.[12]

A recent study involving 86 patients with breast cancer who were initiating AI therapy provides more information on how hair changes over the first year of therapy.[13] The most frequently reported onset of the AI-attributed hair loss was between 3 and 6 months after AI initiation (43.2%), with 67.6% of patients noting hair loss in the mid-scalp (top of head). Factors significantly associated with AI-related hair loss at 1 year were hair loss before AI therapy (OR, 6.5), having a body mass index more than 30 kg/m2 (OR, 6.5), being a current smoker (OR, 7.8), and maternal history of hair loss or hair thinning (OR, 9.1). The results were similar when patients with prior chemotherapy were excluded.


In patients thought to have EIA, clinicians should first rule out other factors that could be causing the loss of locks; these include thyroid disorder, zinc and trace element deficiencies, other endocrine disorders, and fungal or bacterial infections on the scalp.[3,5] Dr Lacouture said that clinicians can recommend "the use of minoxidil 5% once daily to the scalp, along with excluding any other causes of alopecia, such as thyroid, zinc, iron, vitamin D deficiencies."

Management strategies can include using a different hairstyle, camouflaging sprays, hairpieces, or wigs.[5] Women report using hair fibers to make their hair look thicker and tattooing their scalp to mask the problem.[1]

According to a recent literature review, in addition to treatment with topical 5-alpha reductase inhibitors, supplementation with vitamin C and omega-3 fatty acids are the most appropriate treatment agents for EIA without causing an adverse effect on breast cancer prognosis.[3] Omega-3 and -6 fatty acids have been shown to protect and improve hair health through antioxidant effects on the scalp tissue, and they are also known to positively affect the prognosis of breast cancer.[3] Vitamin C may locoregionally reduce hair loss by increased estrogenic effects along with decreased androgenic effects on the scalp, when locally applied with an oil-based buffer that enables vitamin C to pass across the hair texture.[3]

Nurses play a key role in educating patients about hair loss from endocrine therapies and management strategies, and can inform patients of local resources that can help with psychosocial impacts. These include the Look Good Feel Better program, which is designed to help people cope with the effects that cancer treatment can have on their appearance. Workshops include professional advice on how to deal with hair loss using wigs, scarves, hats, hairpieces, and other accessories. Where There's a Need provides hair scarves for women and children who experience hair loss due to medical conditions.

Future studies, such as the ongoing CHANCE (Chemotherapy-Induced Hair Changes and Alopecia, Skin Aging, and Nail Changes in Women With Breast Cancer) trial,[14] will shed light further light on hair loss from endocrine therapies.

Dr Lacouture and Dr Torgerson have disclosed no relevant financial relationships.


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