Psychological Sequelae and Alopecia Among Women with Cancer

Expanding the Availability of Scalp Cooling to All Patients at Risk of Chemotherapy-Induced Alopecia

Alopecia is an undesirable side effect of cancer chemotherapy. The mitigation of alopecia is a desirable adjunct treatment for patients with cancer. FDA-cleared scalp cooling (SC) devices have been successfully used to prevent or reduce chemotherapy-induced alopecia (CIA). This paper provides an understanding of the implementation and value of the new Insurance-Based Billing Model used in the USA for SC and its benefits compared with the original self-pay model. This improved compensation change will result in all patients in need, including underserved and disadvantaged populations, receiving equitable healthcare by allowing access to this valuable supportive care technology.

Availability of Cranial Prostheses for Black Patients at Comprehensive Cancer Centers

PURPOSE

For patients who seek to camouflage cancer-related hair loss, cranial prostheses such as wigs and hair pieces exist. We sought to determine the availability of yaki-textured, type IV curls, and afro wigs at boutiques in Comprehensive Cancer Centers (CCCs).

METHODS

The 56 CCCs in the United States were surveyed to see whether they had an affiliated wig boutique for patients experiencing hair loss. Boutique workers were then asked a series of seven questions regarding cranial prostheses options for patients seeking yaki-textured, type IV curls, and afro wigs. The availability of wigs was compared with US Census data on population size and density of Black residents.

RESULTS

Of the 56 CCCs, 27 (46%) institutions had active affiliated hair boutiques. We were able to reach 19 (70%) of the 27 boutiques, of which 53% (n = 10) offered yaki-textured wigs, 37% (n = 7) offered type IV curls or afro wigs, and 47% (n = 9) offered neither. Two additional boutiques offered in-store catalogs for Black patients who were interested in naturally appearing wigs. Although two institutions offered a wig bank that was free to all patients, neither had yaki-textured or afro wigs in stock. There was no significant relationship between population size or density of Black residents and availability of these wigs.

CONCLUSION

Many Black patients undergoing cancer treatment interested in cranial prosthesis do not have consistent access to wigs with textures comparable with type IV hair at CCCs. With increased inventory of racially inclusive wigs, partnerships with third-party vendors, and support for the previous authorization process, we can better support Black patients experiencing cancer-related hair loss.

Characterization of the role of Facebook groups for patients who use scalp cooling therapy: a survey study

Since the emergence of scalp cooling therapy (SCT) for the prevention of chemotherapy-induced alopecia (CIA), support groups on social media platforms for interested patients have surfaced. Though there are over 20,000 active members across SCT Facebook groups, little is known about how members use this platform. A 23-question survey was posted in five scalp cooling Facebook groups, reaching 219 women. Results indicated that these Facebook groups play clear roles in providing the following: (1) a supportive community for patients, (2) instructions for SCT use, (3) advice regarding insurance coverage and reimbursement, and (4) recommendations for over-the-counter products for hair loss. Despite reported interest in hair loss products, only 5% of patients sought medical treatment from dermatologists. Due to group-specific access restrictions, private Facebook groups provide patients with a protected platform to learn more about SCT from both those with personal experience and SCT company specialists. Providers may consider recommending these online groups to interested patients during the scalp cooling counseling process. As patients with CIA express a growing interest in over-the-counter hair, eyebrow, and eyelash products, it is important for dermatologists to be aware of where their patients obtain recommendations, and further, if these recommendations have clinical evidence of efficacy.

Preventive effect of free radical scavenger edaravone lotion on cyclophosphamide chemotherapy-induced alopecia

PURPOSE

We investigated the inhibitory effect of edaravone (EDR) lotion on chemotherapy-induced alopecia (CIA) to improve the quality of life for patients with cancer.

METHODS

Wistar rats were intraperitoneally injected with cyclophosphamide (CPA, 75 mg/kg) to induce CIA and divided into six groups: (1) Control; (2) EDR 0%; (3) EDR 0.3%; (4) EDR 3%. The TUNEL-positive area was examined histologically, and mRNA expression levels of the apoptosis-related factors, such as B-cell/CLL lymphoma 2 (Bcl-2), and Bcl-2-associated X protein (Bax), were determined.

RESULTS

In the three CPA-treated groups, a decrease in the coverage score (percentage of hairs covered) was observed from days 16 to 18. In addition, coverage scores on day 21, the last day of observation, showed a tendency for the suppression of hair loss to increase, though hair loss was observed in all groups. The coverage scores of the EDR 0.3% and 3% groups after day 17 were significantly higher than those of the EDR 0% group. The TUNEL-positive area of skin tissue on day 16 was extensive in the EDR 0% group and decreased in the EDR 0.3% and 3% groups. The mRNA expression ratio of Bcl-2/Bax on day 21 was maintained at the same level as that of the control group only in the EDR 3% group.

CONCLUSION

This study confirmed the use of EDR lotion to inhibit hair loss, indicating that the clinical application of EDR lotion may improve the quality of life for patients with cancer and their willingness to undergo treatment.

Cytoprotective role of human dental pulp stem cell-conditioned medium in chemotherapy-induced alopecia

BACKGROUND

Chemotherapy-induced alopecia (CIA) is a distressing adverse effect of chemotherapy, with an estimated incidence of 65% and limited treatment options. Cyclophosphamide (CYP) is a common alopecia-inducing chemotherapy agent. Human dental pulp stem cells (DPSCs) secrete several paracrine factors that up-regulate hair growth. Conditioned medium (CM) collected from DPSCs (DPSC-CM) promotes hair growth; culturing mesenchymal stem cells under hypoxic conditions can enhance this effect.

METHODS

The effect of DPSC-CM cultured under normoxic (N-) and hypoxic (H-) conditions against CYP-mediated cytotoxicity in keratinocytes was examined using cell viability assay, lactate dehydrogenase (LDH) cytotoxicity assay, and apoptosis detection. The damage-response pathway was determined in a well-established CIA mouse model by analyzing macroscopic effects, histology, and apoptosis. Reverse transcription-quantitative PCR and Caspase-3/7 activity assay were used to investigate the impact of DPSC-CM on the molecular damage-response pathways in CYP-treated mice. The effect of post-CIA DPSC-CM application on post-CIA hair regrowth was analyzed by macroscopic effects and microstructure observation of the hair surface. Furthermore, to investigate the safety of DPSC-CM as a viable treatment option, the effect of DPSC-CM on carcinoma cell lines was examined by cell viability assay and a subcutaneous tumor model.

RESULTS

In the cell viability assay, DPSC-CM was observed to increase the number of keratinocytes over varying CYP concentrations. Furthermore, it reduced the LDH activity level and suppressed apoptosis in CYP-treated keratinocytes. DPSC-CM exhibited the cytoprotective role in vivo via the dystrophic anagen damage-response pathway. While both N-CM and H-CM downregulated the Caspase-3/7 activity level, H-CM downregulated Caspase-3 mRNA expression. The proportion of post-CIA H-CM-treated mice with > 90% normal hair was nearly twice that of vehicle- or N-CM-treated mice between days 50 and 59 post-depilation, suggesting that post-CIA H-CM application may accelerate hair regrowth and improve hair quality. Furthermore, DPSC-CM suppressed proliferation in vitro in certain carcinoma cell lines and did not promote the squamous cell carcinoma (SCC-VII) tumor growth rate in mice.

CONCLUSIONS

The potentiality of DPSC-CM and H-CM as a promising cytoprotective agent and hair regrowth stimulant, respectively, for CIA needs in-depth exploration.

Ethical, legal, organizational and social issues related to the use of scalp cooling for the prevention of chemotherapy-induced alopecia: A systematic review

INTRODUCTION

Scalp cooling (SC) aims to prevent chemotherapy-induced alopecia. The goal of this systematic review is to tackle ethical, legal, organizational and social issues related to SC.

METHODS

A critical appraisal of the literature was carried out using a systematic review design. MEDLINE, Embase and Web of Science databases were searched up until 2 June 2021. Studies addressing these aspects in English or Spanish were considered. Representatives of both patient associations and professional scientific societies related to the topic participated in the design of the protocol and the review of the findings.

RESULTS

A total of 17 studies were included. Articles were critically appraised using the MMAT and SANRA. Findings were organized into four categories: (1) ethical aspects focused on equal access, gender equity and doctor-patient communication supported by Patient Decision Aids (PtDAs); (2) patient perspective and acceptability; (3) professional perspective and acceptability; (4) organizational aspects focused on accessibility and feasibility.

CONCLUSION

Cancer patients' expectations when using SC need to be adjusted to reduce the potential distress associated with hair loss. PtDAs could help patients clarify their values and preferences regarding SC. Equal access to technology should be guaranteed.

PATIENT OR PUBLIC CONTRIBUTION

In this systematic review, the representatives of the patient associations (Ms. María Luz Amador Muñoz of the Spanish Association Against Cancer [AECC] and Ms. Catiana Martinez Cánovas of the Spanish Breast Cancer Federation [FECMA]) participated in the review of the study protocol, as well as in the results, discussion and conclusions, making their contributions. In the type of design of these studies (systematic reviews), it is not usual to have the direct participation of patients, but in this one, we have done so, as it is a systematic review that is part of a report of the Spanish Network of Health Technology Assessment Agencies (ETS).

Retrospective cohort study of scalp cooling in breast cancer patients

For patients with cancer, alopecia is a common side effect that negatively impacts personal identity, body image, self-esteem, quality of life, and medical decision-making. Scalp cooling is a technique used to prevent alopecia in patients undergoing chemotherapy in which patients wear a cooled cap during chemotherapy infusions, causing localized vasoconstriction of blood vessels on the scalp. Because of the recent emergence of scalp cooling, there is a need to explore further the reasons why patients pursue this treatment. A retrospective chart review of women with breast cancer treated at The Ohio State University was conducted to investigate how factors such as patient age, race, ethnicity, insurance status, stage of cancer, and chemotherapy regimen influenced patients' decisions to incorporate scalp cooling into their treatment plan as compared to those who did not. Findings revealed that patient age, race, insurance status, and chemotherapy regimen were predictors of a patient's likelihood to undergo scalp cooling. Patients diagnosed at younger age and those with private insurance were more likely to utilize scalp cooling. In comparison to White patients, non-White patients were less likely to choose scalp cooling. Furthermore, patients placed on the chemotherapy regimen of AC or AC-T were less likely to pursue scalp cooling than patients on PTCH or TC regimens. These findings provide background for the development of educational resources for both patients interested in this therapy and healthcare providers discussing this treatment option in dermatology and oncology settings.

Post-chemotherapy alopecia: what the dermatologist needs to know

It is estimated that chemotherapy-induced alopecia (CIA) occurs in 65% of chemotherapeutic patients. Forty-seven percent of cancer patients consider hair loss to be the most traumatic aspect of therapy. CIA can be anticipated, depending on the regimen used, and doctors should be aware of the treatments that can minimize it. Careful evaluation before chemotherapy treatment should be performed, and trichoscopy may be useful. Dermatologists do not generally evaluate postchemotherapy alopecia. However, there is an increasing number of reports of permanent chemotherapy-induced alopecia, and these patients require treatment.

Permanent hair loss associated with taxane chemotherapy use in breast cancer: A retrospective survey at two tertiary UK cancer centres

PURPOSE

Taxane chemotherapy is commonly used in the management of breast cancer. Hair loss (alopecia) is an expected side effect which may have a significant effect on quality of life. Alopecia is normally temporary but permanent chemotherapy-induced alopecia (pCIA) is increasingly recognised especially following docetaxel chemotherapy. However, the prevalence following docetaxel is not well understood and there is no published literature for paclitaxel chemotherapy. The aim of this study is to investigate the prevalence and patterns of pCIA resulting from both docetaxel and paclitaxel chemotherapy at two tertiary UK cancer centres.

METHODS

In collaboration between Clatterbridge Cancer Centre and The Christie NHS Foundation Trusts, a retrospective survey was conducted for breast cancer patients who had received taxane chemotherapy in the neoadjuvant and adjuvant settings. Patients who had concluded chemotherapy at least a year previously were contacted by post and invited to participate by completing a questionnaire and returning it to their treatment centre. Data collected included the incidence and pattern of pCIA using the Savin pictorial hair loss scale, and the methods used by patients to manage it. Fisher's exact test was used to compare pCIA between the docetaxel and paclitaxel cohorts.

RESULTS

383 patients responded to the survey (a 63.3% overall response rate). These comprised 245 patients receiving docetaxel and 138 patients treated with paclitaxel. pCIA was reported by 23.3% of patients receiving docetaxel and 10.1% paclitaxel (p < 0.01). Overall 16.7% of patients in both groups reported the ongoing use of products or appliances such as wigs to camouflage their pCIA. In the docetaxel group, pCIA appeared to be more frequent in post-menopausal women than peri- or pre-menopausal women (37.8%, 12.3% and 19.6% respectively [Chi-square test p < 0.01]). Also in the docetaxel group, there appeared to be a trend for more severe scalp alopecia when the patient also received an aromatase inhibitor (AI) or tamoxifen and this difference was most marked in those who had received both an AI and tamoxifen as components of their treatment regime (p = 0.04). The use of scalp cooling was only recorded in the Christie paclitaxel group (n = 12). Of these 12 patients, 83.3% reported no hair loss. While overall rates of permanent eyebrow, eyelash and nostril hair loss were low, this pattern of hair loss appeared more frequent in the paclitaxel than the docetaxel group 4.3% vs. 1.8% (p = 0.29).

CONCLUSIONS

Both docetaxel and paclitaxel may cause permanent scalp hair loss, but it is significantly more prevalent with docetaxel compared with paclitaxel.

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians should counsel patients regarding the risk of permanent alopecia prior to embarking upon taxane chemotherapy and routinely offer scalp cooling if available. More research is required to understand the pathobiology of this important and previously under recognised long-term side effect to enable more active preventive and management approaches.

Lower proximal cup and outer root sheath cells regenerate hair bulbs during anagen hair follicle repair after chemotherapeutic injury

The cell dynamics and cell origin for anagen hair follicle (HF) repair following chemotherapeutic injury are unclear. We first mapped the HF response to cyclophosphamide (CYP) at natural anagen VI in mice. We found that 30-60 mg/kg of CYP leads to dose-dependent HF dystrophy that was spontaneously repaired with anagen resumption, while 120 mg/kg of CYP prematurely induced catagen/telogen entry. To explore how anagen HF repair is achieved in the dystrophic anagen pathway, we analysed the cell dynamics at 30 mg/kg of CYP. Hair bulbs first shrunk due to matrix cell apoptosis associated with DNA double-strand breaks. DNA damage was repaired, and ordered hair bulb structures were restored within 96 hours. Bulge stem cells did not undergo apoptosis nor proliferation. K5⁺ basal lower proximal cup cells and outer root sheath cells quickly replenished the cells in the germinative zone and regenerated the concentric layered structures of the lower HF segment. Therefore, anagen HFs are able to summon extra-bulge progenitor cells in close proximity to the damaged matrix for quick repair after CYP injury.

Stigma in the face of cancer disfigurement: A systematic review and research agenda

INTRODUCTION

An emerging body of work has reported on the psychological impact of disfigurement on cancer patients; however, the extent of research focusing on stigmatisation in this context is unclear. This review aimed to evaluate how stigma associated with disfigurement impacts on cancer patients.

METHODS

A systematic review of literature was conducted using SCOPUS, Web of Science, MEDLINE and PubMed databases. Articles were included if they described a qualitative or quantitative study that investigated the impact of stigma and disfigurement on individuals with cancer and/or their families. Included studies were appraised for methodology and narratively synthesised.

RESULTS

Of the 16 studies which met the inclusion criteria, ten were qualitative and six were quantitative. Publication dates ranged from 1994 to 2020. Results highlighted the varying impact of felt and enacted stigma in people with cancer disfigurement. While individuals cope with stigma in different ways and outcomes can sometimes be positive, most articles documented a negative impact to well-being including emotions such as disgust and shame.

CONCLUSION

This review identified negative and (sometimes) positive consequences of disfigurement and stigma on cancer patients; however, the main finding is that relevant research is in its infancy. Several areas of future research are warranted.

CDK4/6 inhibition mitigates stem cell damage in a novel model for taxane-induced alopecia

Taxanes are a leading cause of severe and often permanent chemotherapy‐induced alopecia. As the underlying pathobiology of taxane chemotherapy‐induced alopecia remains poorly understood, we investigated how paclitaxel and docetaxel damage human scalp hair follicles in a clinically relevant ex vivo organ culture model. Paclitaxel and docetaxel induced massive mitotic defects and apoptosis in transit amplifying hair matrix keratinocytes and within epithelial stem/progenitor cell‐rich outer root sheath compartments, including within Keratin 15+ cell populations, thus implicating direct damage to stem/progenitor cells as an explanation for the severity and permanence of taxane chemotherapy‐induced alopecia. Moreover, by administering the CDK4/6 inhibitor palbociclib, we show that transit amplifying and stem/progenitor cells can be protected from paclitaxel cytotoxicity through G1 arrest, without premature catagen induction and additional hair follicle damage. Thus, the current study elucidates the pathobiology of taxane chemotherapy‐induced alopecia, highlights the paramount importance of epithelial stem/progenitor cell‐protective therapy in taxane‐based oncotherapy, and provides preclinical proof‐of‐principle in a healthy human (mini‐) organ that G1 arrest therapy can limit taxane‐induced tissue damage.

Scalp Cooling: A Patient's Experience

CASE STUDY Ms. X is a 23-year-old female who presented to clinic with stage 2A endometrial cancer of the ovary. At her first visit, Ms. X was prescribed paclitaxel and carboplatin on day 1 for 6 cycles. During the visit, the nurse noted Ms. X could not keep her hands out of her hair; she continually played with it. The nurse, judging by Ms. X's body language, suspected she valued her hair. Ms. X revealed she had been doing some research and wanted to use a cold cap to try and prevent alopecia during her treatment. On the first day of chemotherapy, Ms. X came to the clinic with her mother. They brought a manual cap for scalp cooling and a cooler of dry ice. Her mother was to serve as a "capper" and change the cap at 20- to 30-minute intervals during treatment to keep her scalp cool. Ms. X was made comfortable in an infusion bed, and the cap was applied 30 minutes prior to the start of therapy. Ms. X's mother changed the dry ice caps every 20 minutes throughout the infusion. Ms. X then left it on for 90 minutes following her chemotherapy. After 6 cycles of chemotherapy, Ms. X still had all her hair. She appeared to have retained 100% of her hair, although she estimates that she lost about 5% of her hair. During therapy, she followed the instructions outlined in Table 1. Ms. X reported that she rented the cap for $500 per month and paid $45 per week for the dry ice. Her mother also had to miss work to be the "capper," and this added to the out-of-pocket costs of scalp cooling.

Alectinib-Induced Alopecia in a Patient with Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer

Alectinib, a novel alternative anaplastic lymphoma kinase (ALK) inhibitor, is highly effective against ALK-positive non-small cell lung cancer (NSCLC) and is well tolerated. Molecular targeted agents generally have little contribution to alopecia. We encountered a case of alopecia that developed gradually over 2 months after initiation of alectinib administration for the treatment of ALK-positive NSCLC. The patient had no history of alopecia in previous treatments of cisplatin + pemetrexed and crizotinib. The present case indicates that alopecia should be taken into consideration as toxicity during alectinib treatment, which could adversely affect the psychological and emotional condition and quality of life even in patients treated with specific molecular targeted agents.

Evaluation of Social Support, Quality of Life, and Body Image in Women with Breast Cancer

BACKGROUND

This study was aimed at comparing the quality of life, body image, and perceived social support in women with breast cancer surgery.

PATIENTS AND METHODS

Patients receiving breast-conserving surgery (BCS) (n = 72), mastectomy alone (n = 44), and mastectomy with breast reconstruction (n = 41) were evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the EORTC Breast Cancer Module (QLQ-BR23), the Body Image Scale (BIS) and the Multidimensional Scale of Perceived Social Support (MSPSS).

RESULTS

The results indicated that the BCS group had a better body image compared with the other 2 groups and better role functioning compared with the mastectomy-alone group. In the reconstruction group, body image correlated with perceived social support, especially from family and significant others.

CONCLUSION

These results suggest that a positive perception of a supportive social network can help women with breast reconstruction to better cope with the psychological effects of surgery on their body image.

Quality of life in patients receiving treatment for gynecologic malignancies: Special considerations for patient care

Advances in the treatment of gynecologic cancer have extended the duration of survival of many patients. However, these patients frequently experience a variety of treatment- and disease-related side effects that diminish their quality of life (QOL) during and after treatment; among these are pain, nausea and vomiting, anemia, fatigue, peripheral neuropathy, emotional distress, and sexual dysfunction. Given the gains in survival time, patient care is being expanded to include enhancement or preservation of QOL in addition to early diagnosis and disease treatment, thus treating the whole person. In parallel with this evolution in cancer care, supportive measures are being increasingly recognized as crucial to effective patient management. This paper reviews some of the potential causes of diminished QOL in gynecologic cancer patients and basic treatment strategies for their control, with a focus on short-term QOL issues. It is important that clinicians monitor QOL during the course of the disease and its treatment, utilize procedures and therapeutic agents that take patient preferences and QOL into account, and proactively prevent and treat relevant symptoms.