Last week in shul, I was looking around and noticed that several boys/men had undergone their pre-sefira haircuts. I had a haircut eight weeks ago, so given the Neugut hair genes, I am set for sefira. Nonetheless, it set me to thinking about hair—the recent masechta in Daf Yomi was Nazir, which was suffused with discussions of haircuts under various circumstances. But then there is also Samson and Delilah, as well as David and Absalom.
Since I mostly care about cancer, this led me to reflect on how hair loss constitutes a well known adverse effect for certain chemotherapeutic agents. (My wife, Elie, says she always wondered what I think about in shul!) Over the years I have had innumerable patients suffer from or be hospitalized for the toxic effects of chemotherapy—intractable nausea/vomiting, diarrhea, febrile neutropenia, anemia requiring transfusion, thromboembolic complications, cardiac toxicity, peripheral neuropathy—but as I sit here writing this (and as I mused on the subject in shul during the Rabbi’s sermon), the great majority of the time when a new patient inquires as to the side effects of chemotherapy, the first side effect they ask about is hair loss or alopecia.
I realize that for many, especially women, this is a very visible and disturbing manifestation of their malignancy and some of its treatments. It makes your illness apparent to the world at large. And hair is or can be a crucially important part of one’s psychological presentation and persona (note Absalom above). But I confess to not being able to mount great concern about it as it is obviously neither life-threatening nor permanent, as the hair will usually return when treatment is discontinued. And perhaps the nature of my own scalp makes me less empathetic. On the other hand, there can be no doubt that fear of alopecia does lead some women to refuse chemotherapy or to choose sub-optimal chemotherapy alternatives, so it is a topic that cannot be ignored.
Many conventional cytotoxic chemotherapy agents basically act through mechanisms that poison cells which are proliferating more rapidly than normal cells. Since malignant cells typically proliferate rapidly; this makes them more susceptible to such chemotherapeutic agents. However, these drugs at the same time are likely to affect other normal cells which also are proliferating relatively rapidly. Most prominent in that category are the hematopoietic cells of the bone marrow, so bone marrow suppression is a major issue with these drugs. But hair cells also proliferate rapidly and hence can stop growing or even fall out. As may be expected, the effects are most significant for the hair of the scalp, and much less so for eyebrows or the pubic area where proliferation is extremely slow. The duration of the alopecia may be quite variable, and, in truth, it may take months or years for the hair to regrow.
The likelihood of hair loss is most dependent on the chemotherapeutic agent used and the doses and duration of use. Common causes of alopecia are Cytoxan (cyclophosphamide) and other alkylating agents (busulfan, ifosfamide, thiotepa, etc.), antitumor antibiotics such as Adriamycin (doxorubicin) or mitomycin, taxanes (Taxol (paclitaxel), Taxotere (docetaxel)), and topoisomerase inhibitors (irinotecan, etoposide). Other drugs may cause it but less commonly.
When chemotherapy is discontinued, it can take three to six months for significant regrowth of hair to occur. The new hair may have new characteristics—two-thirds will have graying, curling or straightening. These changes may not persist.
There has been great interest in the use of scalp hypothermia (cooling) for the prevention of alopecia. This is mostly utilized for women undergoing dose-dense adjuvant chemotherapy, but can be used in the setting of other tumors and chemotherapy regimens as well. It is mainly used in the context of short-term chemotherapeutic treatments. When used for patients receiving cyclophosphamide, over 60% of patients still manifest significant alopecia—so this is not a panacea. In contrast, for patients who are receiving a taxane (Taxol or Taxotere) as a single agent, scalp cooling will prevent alopecia in over 60%. It cannot be used for patients undergoing treatment for certain tumors, such as brain tumors or leukemia. While concerns have been raised that metastases could develop in the scalp from the use of these devices, several studies have, for the most part, not found any evidence of this.
Another possible intervention is minoxidil. This is a drug that was developed in the 1950s as an antihypertensive drug and was quite effective, but proved to have the odd side effect of uncontrolled hair growth in odd places when it went on the market, like on the palms. Some bright person had the idea that it could instead be used as a hair growth drug, so it was ultimately approved and marketed as a topical agent as Rogaine for male pattern baldness and is quite effective. It has been used as well for some women with long-term alopecia stemming from taxane use but one must be cognizant of the antihypertensive effects. Randomized trials showed that it did not prevent alopecia but did shorten the time to regrowth of hair after cessation of chemotherapy.
Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York. Email: [email protected].
This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.
