Washington, DC—Hair loss is a well-known side effect of chemotherapy, but alopecia can also occur with endocrine therapy. Endocrine therapy–induced alopecia (ETAL) has received much less attention than chemotherapy-induced alopecia, and many clinical trials of endocrine therapy do not report the incidence of alopecia. The good news is that ETAL is generally mild, and responds to topical and oral drugs.
“In the adjuvant setting, about two-thirds of patients with breast cancer will receive endocrine therapy. There are no controlled studies of the incidence of ETAL, but recent surveys suggest that up to 30% [of patients] will have some degree of hair loss with endocrine therapy,” said Mario E. Lacouture, MD, Director, Oncodermatology Program, Memorial Sloan Kettering Cancer Center, New York City, at the 2017 annual meeting of the Multinational Association of Supportive Care in Cancer.
“ETAL has a different clinical presentation than chemotherapy-induced alopecia. ETAL is usually milder in severity, and tends to be localized at the frontal hairline,” Dr Lacouture said.
A survey of 868 patients receiving endocrine therapy with an aromatase inhibitor or tamoxifen found hair loss in 22.4% and hair thinning in 31.8%. A separate case history series of 15 patients receiving tamoxifen and an aromatase inhibitor found tapering of the hair shaft, he noted.
In a meta-analysis of 35 phase 2 to 3 clinical trials with a total of 13,415 patients with breast cancer receiving endocrine therapy, 94% of the trials did not report alopecia. Among those who did, the incidence of all-grade alopecia was 4.4%, and grade ≥2 was 1.4%; tamoxifen was associated with a 9.3% incidence of alopecia, and fulvestrant with an incidence of 2.3%.
Dr Lacouture and colleagues are currently conducting a prospective, longitudinal study called CHANCE (Chemotherapy-Induced Hair, Skin, and Nail Changes in Women with Breast Cancer) where patients will be followed from initiation of chemotherapy or hormone therapy for 3 years. Hair loss will be measured at months 3 and 6. Cohorts include patients treated with chemotherapy and endocrine therapy (evenly divided between tamoxifen and aromatase inhibitors). Hair density and thickness of hair shafts will be measured by standard instruments.
“The most frequent question that women entering the trial ask is, ‘Will I permanently lose my hair from chemotherapy or with hormones?’” Dr Lacouture told the audience.
Patterns of Hair Loss
A cross-sectional analysis of patients treated at the Memorial Sloan Kettering Cancer Center dermatology department classified 2234 patients with onset of hair loss 6 to 12 months after initiation of hormone therapy. A combination of complete recession of the frontal hairline and the “monk pattern” of hair loss (grade 1) was observed in 96% of patients. The majority of patients had a frontal pattern (85%), and hair loss in the crown was observed in 65%.
Quality of Life and Hair Loss
“There is no alopecia-specific quality of life instrument, so we translated from a dermatologic quality of life instrument called Hairdex PRO. In 40 patients, we found that hair loss had a significant impact on patients’ emotional state and self-confidence. They are worried that the hair loss will get worse and frightened when they see hair on their hairbrushes,” Dr Lacouture explained.
Many treatments for hair loss have been proposed throughout the years. Dr Lacouture showed attendees a chart of the alphabet with every letter having ≥1 suggested therapies reported as being effective.
“The hair care industry is a $37 billion industry in the United States,” he explained.
ETAL usually responds to topical minoxidil or to oral spironolactone, Dr Lacouture said. Among 41 patients with ETAL treated with topical minoxidil, 75% had moderate to significant improvement.
“It is important to take photos to show patients they have improved. Otherwise they don’t believe it. Hair is like money—you can never have enough,” he said.
Patients with ETAL can also be followed with trichoscopy to determine the increase in the number of terminal hairs, and an increase in the thickness of each hair shaft.