Management of chemotherapy-induced alopecia (CIA): A comprehensive review and future directions

Results of the Dutch scalp cooling registry in 7424 patients: analysis of determinants for scalp cooling efficacy

BACKGROUND

Chemotherapy-induced alopecia is a common consequence of cancer treatment with a high psychological impact on patients and can be prevented by scalp cooling (SC). With this multi-center patient series, we examined the results for multiple currently used chemotherapy regimens to offer an audit into the real-world determinants of SC efficacy.

MATERIALS AND METHODS

The Dutch Scalp Cooling Registry collected data on 7424 scalp-cooled patients in 68 Dutch hospitals. Nurses and patients completed questionnaires on patient characteristics, chemotherapy, and SC protocol. Patient-reported primary outcomes at the start of the final SC session included head cover (HC) (eg, wig/scarf) use (yes/no) as a surrogate for patient satisfaction with SC and WHO score for alopecia (0 = no hair loss up to 3 = total alopecia) as a measure of scalp cooling success. Exhaustive logistic regression analysis stratified by chemotherapy regimen was implemented to examine characteristics and interactions associated with the SC result.

RESULTS

Overall, over half of patients (n = 4191, 56%) did not wear a HC and 53% (n = 3784/7183) reported minimal hair loss (WHO score 0/1) at the start of their final treatment. Outcomes were drug and dose dependent. Besides the chemotherapy regimen, this study did not identify any patient characteristic or lifestyle factor as a generic determinant influencing SC success. For non-gender specific cancers, gender played no statistically significant role in HC use nor WHO score.

CONCLUSIONS

Scalp cooling is effective for the majority of patients. The robust model for evaluating the drug and dose-specific determinants of SC efficacy revealed no indications for changes in daily practice, suggesting factors currently being overlooked. As no correlation was identified between the determinants explaining HC use and WHO score outcomes, new methods for evaluation are warranted.

Therapeutic Effect of Superficial Scalp Hypothermia on Chemotherapy-Induced Alopecia in Breast Cancer Survivors

Alopecia is a common adverse effect of neoadjuvant or adjuvant chemotherapy in patients with early breast cancer. While hair typically regrows over time, more than 40% of patients continue to suffer from permanent partial alopecia, significantly affecting body image, psychological well-being, and quality of life. This concern is a recognized reason why some breast cancer patients decline life-saving chemotherapy. It is critical for healthcare professionals to consider the impact of this distressing side effect and adopt supportive measures to mitigate it. Among the various strategies investigated to reduce chemotherapy-induced alopecia (CIA), scalp cooling has emerged as the most effective. This article reviews the pathophysiology of CIA and examines the efficacy of different scalp cooling methods. Scalp cooling has been shown to reduce the incidence of CIA, defined as less than 50% hair loss, by 50% in patients receiving chemotherapy. It is associated with high patient satisfaction and does not significantly increase the risk of scalp metastasis or compromise overall survival. Promising new scalp cooling technologies, such as cryogenic nitrogen oxide cryotherapy, offer the potential to achieve and maintain lower scalp temperatures, potentially enhancing therapeutic effects. Further investigation into these approaches is warranted. Research on CIA is hindered by significant heterogeneity and the lack of standardised methods for assessing hair loss. To advance the field, further interdisciplinary research is crucial to develop preclinical models of CIA, establish a uniform, internationally accepted and standardised classification system, and establish an objective, personalised prognosis monitoring system.

DNA methylation of microRNA-365-1 induces apoptosis of hair follicle stem cells by targeting DAP3

Background

DNA methylation is a crucial epigenetic alteration involved in diverse biological processes and diseases. Nevertheless, the precise role of DNA methylation in chemotherapeutic drug-induced alopecia remains unclear. This study examined the role and novel processes of DNA methylation in regulating of chemotherapeutic drug-induced alopecia.

Methods

A mouse model of cyclophosphamide (CTX)-induced alopecia was established. Hematoxylin-eosin staining and immunohistochemical staining for the Ki67 proportion and a mitochondrial membrane potential assay (JC-1) were performed to assess the structural integrity and proliferative efficiency of the hair follicle stem cells (HFSCs). Immunofluorescence staining and real-time fluorescence quantitative PCR (RT-qPCR) were performed to determine the expression levels of key HFSC markers, namely Lgr5, CD49f, Sox9, CD200, and FZD10. Differential DNA methylation levels between the normal and CTX-induced model groups were determined through simple methylation sequencing and analyzed using bioinformatics tools. The expression levels of miR-365-1, apoptosis markers, and DAP3 were detected through RT-qPCR and western blotting. In parallel, primary mouse HFSCs were extracted and used as a cell model, which was constructed using 4-hydroperoxycyclophosphamide. The luciferase reporter gene assay was conducted to confirm miR-365-1 binding to DAP3. To measure the expression of relevant indicators, superoxide dismutase (SOD) and malondialdehyde (MDA) kits were used. Methylation-specific PCR (MS-PCR) was performed to determine DNA methylation levels. The regulatory relationship within HFSCs was confirmed through plasmid overexpression of miR-365-1 and DAP3.

Result

In the alopecia areata model, a substantial number of apoptotic cells were observed within the hair follicles on the mouse backs. Immunofluorescence staining revealed that the expression of HFSC markers significantly reduced in the CTX group. Both RT-qPCR and western blotting demonstrated a noteworthy difference in DNA methyltransferase expression. Simple methylation sequencing unveiled that DNA methylation substantially increased within the dorsal skin of the CTX group. Subsequent screening identified miR-365-1 as the most differentially expressed miRNA. miR-365-1 was predicted and confirmed to bind to the target gene DAP3. In the CTX group, SOD and ATP expression markedly reduced, whereas MDA levels were significantly elevated. Cellular investigations revealed 4-HC-induced cell cycle arrest and decreased expression of HFSC markers. MS-PCR indicated hypermethylation modification of miR-365-1 in the 4-HC-induced HFSCs. The luciferase reporter gene experiment confirmed the binding of miR-365-1 to the DAP3 promoter region. miR-365-1 overexpression dramatically reduced apoptotic protein expression in the HFSCs. However, this effect was slightly reversed after DAP3 overexpression in lentivirus.

Conclusion

This study explored the occurrence of miR-365-1 DNA methylation in chemotherapeutic drug-induced alopecia. The results unveiled that miR-365-1 reduces cell apoptosis by targeting DAP3 in HFSCs, thereby revealing the role of DNA methylation of the miR-365-1 promoter in chemotherapeutic drug-induced alopecia.

Chemotherapy induced alopecia in breast cancer patients: A monocentric prospective study

INTRODUCTION

Alopecia is one of the main adverse events of chemotherapy in breast cancer. However, its impact is often ignored and underestimated by clinicians. Our aim was to evaluate the quality of life of breast cancer patients with chemotherapy induced alopecia.

METHODS

We conducted a prospective study including 72 breast cancer patients who developed alopecia on or after stopping chemotherapy in the last 6 months. Clinical information and characteristics of alopecia were assessed using a self-prepared questionnaire. DLQI score was used to evaluate patients' quality of life.

RESULTS

We interviewed a total of 72 women with a mean age of 53.5 ± 6 years. Alopecia appeared soon after the first course in 62.5%. All patients actively tried to hide induced hair fall (either by a hat in 6.9% or by a headscarf in 93.1%). Quality of life was impacted in 97.2% of patients with a median DLQI score of 6.5. Women who did not underwent mastectomy were significantly more bothered by hair loss than those who had radical surgery (78.1% vs 55%, p = 0.04). Working status was a significant predictor factor of a bad quality of life due to alopecia (100% in working women vs 58.3% in homemaker or retired patients, p = 0.006).

CONCLUSION

Chemotherapy induced alopecia had a negative impact on quality of life of patients with breast cancer, especially in working women and those who did not have radical surgery. Prior wearing of headscarves did not impact significantly the DLQI score.

Prevention and Treatment of Chemotherapy-Induced Alopecia: What Is Available and What Is Coming?

Millions of new cancer patients receive chemotherapy each year. In addition to killing cancer cells, chemotherapy is likely to damage rapidly proliferating healthy cells, including the hair follicle keratinocytes. Chemotherapy causes substantial thinning or loss of hair, termed chemotherapy-induced alopecia (CIA), in approximately 65% of patients. CIA is often ranked as one of the most distressing adverse effects of chemotherapy, but interventional options have been limited. To date, only scalp cooling has been cleared by the US Food and Drug Administration (FDA) to prevent CIA. However, several factors, including the high costs not always covered by insurance, preclude its broader use. Here we review the current options for CIA prevention and treatment and discuss new approaches being tested. CIA interventions include scalp cooling systems (both non-portable and portable) and topical agents to prevent hair loss, versus topical and oral minoxidil, photobiomodulation therapy (PBMT), and platelet-rich plasma (PRP) injections, among others, to stimulate hair regrowth after hair loss. Evidence-based studies are needed to develop and validate methods to prevent hair loss and/or accelerate hair regrowth in cancer patients receiving chemotherapy, which could significantly improve cancer patients’ quality of life and may help improve compliance and consequently the outcome of cancer treatment.

Body image experience of women with breast cancer: A meta-synthesis

BACKGROUND

Body image is a multidimensional concept that involves the mental image of the human body and the feeling of being oneself throughout existence. Treatment for breast cancer causes several bodily changes that affect women's body image.

AIMS

This meta-synthesis aims to synthesise and interpret primary qualitative studies on the experience of body image in women undergoing treatment for breast cancer.

METHODS

A qualitative meta-synthesis was conducted employing systematic searches in six databases (PubMed, CINAHL, SCOPUS, Web of Science, PsycINFO, and LILACS). Data analysis was performed according to thematic synthesis.

RESULTS

Forty studies were included. Five descriptive themes were identified: (1) actively saying goodbye to body image; (2) the rupture of body image; (3) the sacrifice of body image in exchange for life; (4) body image as a vehicle for social expression; and (5) resignation of the alterated body image. These themes were understood through one analytical theme: Half-woman: body image of the woman with breast cancer.

CONCLUSION

The experience of body image in the context of breast cancer is a dynamic phenomenon, which involves dismissal, rupture, and resignation and occurs mediated by interpersonal contact.

Evaluation of the CNC® prosthetic system in recurrent breast cancer patients with chemotherapy-induced alopecia: a pilot study

BACKGROUND

Chemotherapy-induced alopecia (CIA), although generally reversible, is felt as extremely distressing by patients with breast cancer. A certified medical device (Capelli Naturali a Contatto^®-CNC^®) was produced to provide patients with a personalized scalp prosthesis, reproducing the patient's original hair, resistant to any type of everyday or sporting activity, and hairdressing.

AIMS

The present study aimed to evaluate the impact of the CNC^® device on the patient's perception of their body image, psychological wellbeing, satisfaction, strengths and weakness of the CNC^® device.

METHOD

A pilot study was carried out on 21 patients affected by CIA due to recurrent breast cancer. A mixed quantitative/qualitative method was used, including administering a questionnaire and a focus group.

RESULTS

Based on the Body Image Scale, body image perception improved after 3 and 6 months using the device in the 20 patients who answered the questionnaire. No significant change over time emerged for the six dimensions investigated by the Italian version of the Psychological Well-Being Scale. The thematic analysis of the focus groups showed six themes: definition of the prosthetic device, acceptance of the proposal, experience with the conventional wig, strengths, weaknesses, economic issues.

CONCLUSION

Compared to the previous experience of CIA and the standard wig, the use of the CNC^® device improved everyday life and may be proposed to women undergoing chemotherapy and expecting alopecia to prevent discomfort, social embarrassment, and compromised body image.

Oral Minoxidil for Chemotherapy-Induced Alopecia

Introduction

Chemotherapy-induced alopecia (CIA), one of the most dramatic side effects of chemotherapy, occurs in approximately 65% of patients receiving cytotoxic drugs.

Case Presentation

We report the case of a patient, 64 years old, affected by chemotherapy-induced alopecia treated with oral minoxidil with good results.

Discussion/Conclusion

Our case may be useful in the literature to propose a new therapy for this pathology that is fundamentally very difficult to treat.

Safety analyses from the phase 3 ASCENT trial of sacituzumab govitecan in metastatic triple-negative breast cancer

Sacituzumab govitecan (SG) is an anti-Trop-2 antibody-drug conjugate with an SN-38 payload. In the ASCENT study, patients with metastatic triple-negative breast cancer (mTNBC) relapsed/refractory to ≥2 prior chemotherapy regimens (≥1 in the metastatic setting), received SG or single-agent treatment of physician's choice (eribulin, vinorelbine, capecitabine, or gemcitabine). This ASCENT safety analysis includes the impact of age and UGT1A1 polymorphisms, which hinder SN-38 detoxification. SG demonstrated a manageable safety profile in patients with mTNBC, including those ≥65 years; neutropenia/diarrhea are key adverse events (AE). Patients with UGT1A1 *28/*28 genotype versus those with 1/*28 and *1/*1 genotypes had higher rates of grade ≥3 SG-related neutropenia (59% vs 47% and 53%), febrile neutropenia (18% vs 5% and 3%), anemia (15% vs 6% and 4%), and diarrhea (15% vs 9% and 10%), respectively. Individuals with UGT1A1 *28/*28 genotype should be monitored closely; active monitoring and routine AE management allow optimal therapeutic exposure of SG.

"Dear hair loss"-illness perceptions of female patients with chemotherapy-induced alopecia

OBJECTIVE

Chemotherapy-induced alopecia (CIA) is one of the most common and distressing side effects of chemotherapy treatment. This study aims to assess the illness perceptions of female patients dealing with CIA, and their associations with demographic and clinical characteristics, coping strategies, and quality of life. The secondary aim was to compare the illness perceptions of patients with CIA with other samples, to help elucidate the specific perceptions of patients with CIA.

METHOD

Forty female patients at risk of severe hair loss due to chemotherapy treatment were included at the oncological daycare unit of a teaching hospital in the Netherlands. Patients were asked to complete the Brief-Illness Perception Questionnaire (B-IPQ) and the Hair Quality of Life (Hair-QoL) questionnaire.

RESULTS

Illness perceptions indicated that although patients understood their hair loss, they lacked being able to make sense of managing it, negatively impacting patients' lives. Psychological quality of life was significantly correlated with the B-IPQ domains: consequences, degree of concern, and emotional response. Social quality of life was significantly correlated with psychological quality of life. Patients with CIA felt significantly less able to manage their hair loss, compared to patients with breast cancer and psoriatic arthritis.

CONCLUSION

As patients' beliefs of being able to manage their hair loss are important for adopting and maintaining adequate coping behaviors, additional effort of health care providers in fostering patients' sense of control is indicated, focusing on patients' strengths during and after chemotherapy treatment. In the context of developing interventions for patients with CIA, consequences, concern, and emotional response are the major dimensions that should be taken in account to help patients deal with hair loss.

Side effect prediction based on drug-induced gene expression profiles and random forest with iterative feature selection

One in every ten drug candidates fail in clinical trials mainly due to efficacy and safety related issues, despite in-depth preclinical testing. Even some of the approved drugs such as chemotherapeutics are notorious for their side effects that are burdensome on patients. In order to pave the way for new therapeutics with more tolerable side effects, the mechanisms underlying side effects need to be fully elucidated. In this work, we addressed the common side effects of chemotherapeutics, namely alopecia, diarrhea and edema. A strategy based on Random Forest algorithm unveiled an expression signature involving 40 genes that predicted these side effects with an accuracy of 89%. We further characterized the resulting signature and its association with the side effects using functional enrichment analysis and protein-protein interaction networks. This work contributes to the ongoing efforts in drug development for early identification of side effects to use the resources more effectively.