Analysis of quantitative changes in hair growth during treatment with chemotherapy or tamoxifen in patients with breast cancer: a cohort study

[Alopecia due to chemotherapeutics, hedgehog inhibitors, targeted antibody therapies and immune checkpoint inhibitors : Pathogenesis, clinical picture, diagnostics and prophylaxis]

BACKGROUND

The incidence and severity of alopecia vary mainly depending on the chemotherapeutic agent used or other drug groups. The pathogenetic characteristics of the different forms of alopecia are reflected in the clinical presentation and, in some cases, in the resulting recommendations for prophylaxis.

OBJECTIVES

To provide an overview of the pathogenesis, clinical presentation, diagnosis and prophylaxis of alopecia with chemotherapeutic agents, hedgehog inhibitors, targeted therapies and immune checkpoint inhibitors.

MATERIALS AND METHODS

Based on the current S3 guideline "Supportive therapy", an extensive literature search was carried out.

RESULTS AND CONCLUSION

Chemotherapy-induced hair loss (CIA) occurs in up to 65% of cases. Anagen effluvium is observed as early as 1-3 weeks after the start of treatment and is reversible in most cases. Alopecia associated with inhibitors of the Sonic Hedgehog signaling pathway (HHIA) such as vismodegib or sonidegib are observed in up to 60% of cases. They are characterized by telogen effluvium. BRAF or immune checkpoint inhibitors lead significantly less frequently to alopecia (BRAFA, CPIA). According to taxane-based chemotherapy protocols, scalp cooling can help to prevent higher-grade CIA. If CIA or other forms of alopecia are expected, early contact with self-help organizations and early prescriptions for wigs should be offered.

Chronic Telogen Effluvium: Is it a Distinct Condition? A Systematic Review

BACKGROUND

Whilst there are several recognised explanations for persistent telogen-phase hair loss, for a proportion of cases, no clear underlying cause can be identified. These cases have been given the diagnostic label chronic telogen effluvium: a poorly characterised condition where there is legitimate uncertainty as to whether it represents a truly distinct disorder.

OBJECTIVE

The aim of this review was to evaluate published cases of purported chronic telogen effluvium and how strongly they support its existence as a distinct disorder.

METHODS

We systematically reviewed the literature identified from searching Embase, MEDLINE and Web-of-Science. An additional manual search was performed from the reference lists of publications identified. The review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Joanna Briggs Institute's checklists for case reports, case-series, case-control studies and analytical cross-sectional-studies were used to appraise the quality of identified articles.

RESULTS

Eighteen studies (comprising five case-series, seven cross-sectional studies, three case-control studies, one case report, one quasi-experimental study and one diagnostic-accuracy study) were included for evaluation, containing 1628 cases. Eleven were rated of good quality. 97.5% of all cases were female. No studies documented that they had excluded all possible causes of telogen hair shedding. Only three studies (encompassing eight cases) featured a prospective follow-up. All eight studies that undertook biopsies reported a normal terminal to vellus hair ratio in the samples analysed. No studies objectively evaluated the influence of hair length or psychological distress/preoccupation on the likelihood of being diagnosed with chronic telogen effluvium.

CONCLUSIONS

The lack of a consensual consistent definition for chronic telogen effluvium is a significant limitation. Many cases presently labelled chronic telogen effluvium likely either represent early female pattern hair loss or incipient secondary telogen effluvium owing to an unidentified underlying secondary cause. Where triggering factors have been definitively excluded, hair shedding may represent an alteration in the hair cycle away from normal total asynchronous cycling. Some cases may also represent a preoccupation with normal hair shedding in anxious long-haired individuals.

Clinicopathologic Characteristics and Response to Treatment of Persistent Chemotherapy-Induced Alopecia in Breast Cancer Survivors

Importance

Alopecia induced by classic chemotherapy affects up to 65% of patients and is usually reversible. However, there are increasing reports of persistent chemotherapy-induced alopecia (pCIA), especially for patients treated with taxane-containing chemotherapy regimens.

Objective

To analyze the clinicopathologic characteristics and response to treatment of patients with pCIA after chemotherapy for breast cancer.

Design, Setting, and Participants

In this case series, a retrospective evaluation was performed of patients with a diagnosis of pCIA after chemotherapy for breast cancer in 4 specialist hair clinics from November 1, 2011, to February 29, 2020.

Main Outcomes and Measures

Clinical, trichoscopic, and histopathologic characteristics and treatment outcomes were analyzed. For patients who presented with diffuse alopecia or diffuse rarefaction of hair over the midfrontal scalp with widening of the central part line and preservation of the frontal hairline, the Sinclair scale (grades 1-5, where 1 indicates normal hair density and 5 indicates the most severe stage of hair loss, with little or no hair in the centroparietal region) was used to assess severity.

Results

One hundred patients (99 women [99%]; mean age at presentation, 54.0 years [range, 29.0-74.1 years]) were included. Most patients had diffuse nonscarring alopecia (n = 39), female pattern hair loss (n = 55), or male pattern hair loss (n = 6). Six patients developed cicatricial alopecia. Taxane-containing regimens were used for most patients (92 [92%]) and were associated with more severe alopecia than regimens that did not contain taxanes (median Sinclair grade, 4 [IQR, 3-5] vs 2 [IQR, 2-2.5]; P < .001). A total of 76 of 86 patients (88%) had trichoscopic signs indistinguishable from those of androgenetic alopecia. Of 18 patients who had biopsies, 14 had androgenetic alopecia-like features, 2 had cicatricial alopecia, and 2 had features of both. Both topical and oral minoxidil, sometimes combined with antiandrogen therapy, were associated with an improvement in hair density (median Sinclair grade, 4 [IQR, 3-5] before treatment vs 3 [IQR, 2-4] after treatment; P < .001).

Conclusions and Relevance

This case series outlines previously unreported features of pCIA in patients with breast cancer, including a trichoscopic description. Cosmetically significant regrowth was achieved for a significant proportion of patients with topical or systemic treatments, suggesting that pCIA may be at least partly reversible.

PPARγ signaling protects hair follicle stem cells from chemotherapy-induced apoptosis and epithelial-mesenchymal transition

BACKGROUND

Permanent chemotherapy-induced alopecia (pCIA), for which preventive interventions remain limited, can manifest with scarring. While the underlying pathomechanisms of pCIA are unclear, depletion of epithelial hair follicle (HF) stem cells (eHFSCs) is likely to play a role.

OBJECTIVES

To explore the hypothesis that eHFSCs undergo pathological epithelial-mesenchymal transition (EMT) besides apoptosis in pCIA, thus explaining the scarring phenotype. Furthermore, we tested whether a PPARγ modulator can prevent pCIA-associated pathomechanisms.

METHODS

Organ-cultured human scalp HFs were treated with the cyclophosphamide metabolite, 4-hydroperoxycyclophosphamide (4-HC). Additionally, HFs were pre-treated with the agnostic PPARγ modulator, N-Acetyl-GED-0507-34-Levo (NAGED), which we had previously shown to promote K15 expression and antagonize EMT in eHFSCs.

RESULTS

In accordance with anticipated hair bulb cytotoxicity, dystrophy and catagen induction, 4-HC promoted apoptosis along with increased p53 expression, DNA damage and pathological EMT in keratin 15+ (K15) bulge eHFSCs, as evidenced by decreased E-cadherin expression and the appearance of fibronectin- and vimentin-positive cells in the bulge. Pre-treatment with NAGED protected from 4-HC-induced hair bulb cytotoxicity/dystrophy, and halted apoptosis, p53 up-regulation, and EMT in the bulge, thereby significantly preventing the depletion of K15+ human eHFSCs ex vivo.

CONCLUSIONS

A cyclophosphamide metabolite alone suffices to damage and deplete human scalp eHFSCs by promoting apoptosis, DNA damage, and EMT ex vivo. Therefore, pCIA-therapeutic strategies need to target these pathological processes. Our data introduce the stimulation of PPARγ signaling as a novel intervention strategy for the prevention of pCIA, given the ability of NAGED to prevent chemotherapy-induced eHFSCs damage ex vivo.

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.

Prospective observational study of chemotherapy-induced alopecia after sequential FEC + taxane and the effects of age in breast cancer patients

BACKGROUND

Chemotherapy-induced alopecia (CIA) is a common and quite distressing adverse effects of chemotherapy. There are few detailed observational studies of CIA or of the impact of age on CIA. We performed a prospective observational study to investigate the prevalence and degree of CIA, including CIA of eyebrows, eyelashes, and body, and we examined patient's recovery from CIA, focusing on age-depending effects.

METHODS

We analyzed 68 female Japanese patients with breast cancer (median age 53 years, range 29-76 years) who received perioperative adjuvant chemotherapy with fluorouracil/epirubicin/cyclophosphamide (FEC) and taxane. A questionnaire was administered at the point of chemotherapy completion and 6 and 12 months after chemotherapy completion.

RESULTS

CIA occurred in all patients, with severe hair loss irrespective of age. CIA occurred mainly in the scalp but also in the eyebrows, eyelashes, and body for most of the patients. There were significant associations between the patient's age and the onset of hair regrowth in the eyebrows, eyelashes, and body. The onset of eyebrows, eyelash, and body hair growth were significantly shorter in the premenopausal patients. Any hair changes (e.g., thinned diameter, softer texture, curlier structure) were reported by 85.3% of the patients.

CONCLUSIONS

Severe CIA occurred in all 68 patients who received FEC and taxane chemotherapy. The present findings provide the first data demonstrating that age was not associated with the degree or incidence of hair loss, but age affected the recovery from CIA. These results contribute more accurate information provision and insights regarding the proper treatment of CIA.

Toxicités dermatologiques après prise en charge d’un cancer du sein : intérêt d’une cure thermale en soins oncologiques de support

Dermatological toxicities (affecting the skin, mucous membranes, nails or hair) are frequently associated with cancer treatments. They can represent a real burden for patients, with physical, social and psychological repercussions. These dermatological adverse events can also persist long after the treatment has ended, especially after treatment with cytotoxic chemotherapeutic agents such as taxanes. There is a clear need for the development of suitable supportive care measures to help manage these toxicities. The place of a hydrotherapy treatment in this context remains to be clarified. This article summarizes the main data available on the quality of life, and more specifically the dermatological quality of life, of patients for whom hydrotherapy was proposed after breast cancer. © 2020 Elsevier Masson SAS. All rights reserved.

Overall clinical and trichoscopic analysis performed in patients who underwent pressurized intraperitoneal aerosol chemotherapy (PIPAC) treatment for peritoneal carcinomatosis - initial trial preliminary report

Introduction

Cutaneous adverse events are among the remaining problematic issues of current oncology. The term peritoneal carcinomatosis (PC) refers to the advanced cancer stage. The innovative treatment of PC includes the use of pressurized intraperitoneal aerosol chemotherapy (PIPAC).

Aim

To present a preliminary report from an initial trial aimed at an overall clinical and trichoscopic analysis performed in patients who underwent PIPAC treatment due to PC.

Material and methods

For all steps of this study we obtained the consent of the local bioethics commission #KB 196/2018. Three different hair assessment methods were used in our study: 1) general clinical and patient self-feeling assessment; 2) hair pull test; 3) and trichoscopic analysis.

Results

No hair or scalp disorders were noted in the observation period. In the self-feeling test assessment the vast majority recognized their hair as being of comparable quality or even better in quality compared to previous forms of chemotherapy they had undergone. In all patients we observed a reduction of hair loss in the pull test in the hospitalization period. In trichoscopic analysis we found all determinants and signs of hair disorders in the assessed group.

Conclusions

The PIPAC is safe and is not a burdensome or aggressive form of therapy, especially according to the very important factors influencing the potential quality of hair and hair loss. The authors, however, realize that to obtain comprehensive results and evaluate this novel and promising method we need to perform more research without any limitations like those in our study.

COOLHAIR: a prospective randomized trial to investigate the efficacy and tolerability of scalp cooling in patients undergoing (neo)adjuvant chemotherapy for early breast cancer

PURPOSE

Chemotherapy-induced alopecia (CIA) is a distressing side effect for women with breast cancer undergoing chemotherapy. Scalp cooling is a method aiming to prevent CIA, but its efficacy is not well defined. Randomized trials until recently and at the time this trial was designed have been lacking.

METHODS

Patients undergoing (neo)adjuvant chemotherapy for early breast cancer (EBC) were randomized to scalp cooling (CAP) or observation (NoCAP). All patients received 18-24 weeks of anthracycline- and/or taxane-based chemotherapy. The primary endpoint was patient-reported rate of alopecia according to a modified version of the Dean Scale. Hair preservation was defined as hair loss ≤ grade 2 (≤ 50%). Secondary endpoints were rate of alopecia determined by medical staff, rate of wig/scarf use, tolerability as well as quality of life (QoL).

RESULTS

Seventy-nine patients were randomized. Hair preservation was observed in 39.3% of patients in the CAP arm versus 0% in the NoCAP arm (p < 0.001). Wig/scarf use was significantly less frequent in the CAP group (40.7% vs 95.5% outside home before cycle 3, p < 0.001). The drop-out rate was 31.7% and 34.2% in the CAP and NoCAP arm, respectively. Main reasons for drop-out were hair loss, adverse events (CAP), and randomization into control arm. We observed no differences in efficacy between anthracycline-based and non-anthracycline-based regimens. QoL did not differ between the study arms.

CONCLUSIONS

This trial adds to the evidence that scalp cooling effectively prevents CIA in a meaningful number of patients. This option should be made available for patients undergoing (neo)adjuvant chemotherapy for EBC.

The immunomodulatory activities of licorice polysaccharides (Glycyrrhiza uralensis Fisch.) in CT 26 tumor-bearing mice

BACKGROUND

The increasing use of complementary and alternative medicine (CAM) has kindled the need for scientific evaluation of the mechanism of action of CAMs. Although, licorice, a common ingredient in many Traditional Chinese medicine (TCM) has attracted great attention for its antitumor and immunomodulatory activities, the mechanism of action of its polysaccharides is still unclear. Here we report the immunomodulatory activity of licorice polysaccharides in vivo.

METHODS

The differential anticancer activities of licorice polysaccharides by tumorigenesis and immunomodulation was evaluated in vivo. Six weeks old, 120 CT-26 tumor bearing BALB/c mice, weighing 20 ± 2 g were used. They were randomly divided into six groups, three groups receiving high molecular weight (fraction A), low molecular weight (fraction B) polysaccharides and crude extract (fraction C); positive, negative and normal groups receiving cytoxin, saline and normal diet respectively. Weight of mice and tumors was determined and tumorigenicity assay calculated to determine the anticancer effects. Immunomodulatory potential was determined by immune organ indices, immune cell population and serum cytokine levels using immune organ weight and index, flow cytometry and cytokine/chemokine bead panel kit respectively.

RESULTS

Licorice polysaccharides exhibited immunomodulatory activities in CT 26 tumor bearing BALB/c mice. The polysaccharides significantly suppressed tumor growth and increased immune organ index. Furthermore, the immunomodulatory effect was evident with activation of CD4+ and CD8+ immune cells population. The polysaccharides also affected the production of various cytokines, by increasing IL 2, IL 6, IL 7 levels and a decreasing TNFα levels.

CONCLUSION

In summary, licorice polysaccharide especially of low molecular weight exhibit anticancer and immunomodulatory activities by suppressing tumor growth and improving general health of mice. They also augment the thymus/spleen index and population of T lymphocytes. Furthermore, the polysaccharides enhance the levels of serum antitumor cytokines, IL 2, IL 6 and IL 7 while decreasing pro-tumor cytokine TNFα.

Alopecia in general medicine

Appreciation of different types of hair loss (alopecia) that may be encountered in hospital medicine is important to ensure accurate diagnosis and management, identify underlying medical conditions or treatments that may present with increased hair loss, recognise autoimmune alopecias and their associations, and understand the significant psychological impact of hair loss on an individual. This article discusses common causes of hair loss, as well as those conditions that may be associated with systemic disease, relevant to a general physician.

Protecting the normal in order to better kill the cancer

Chemotherapy is the only option for oncologists when a cancer has widely spread to different body sites. However, almost all currently available chemotherapeutic drugs will eventually encounter resistance after their initial positive effect, mainly because cancer cells develop genetic alterations, collectively coined herein as mutations, to adapt to the therapy. Some patients may still respond to a second chemo drug, but few cases respond to a third one. Since it takes time for cancer cells to develop new mutations and then select those life-sustaining ones via clonal expansion, "run against time for mutations to emerge" should be a crucial principle for treatment of those currently incurable cancers. Since cancer cells constantly change to adapt to the therapy whereas normal cells are stable, it may be a better strategy to shift our focus from killing cancer cells per se to protecting normal cells from chemotherapeutic toxicity. This new strategy requires the development of new drugs that are nongenotoxic and can quickly, in just hours or days, kill cancer cells without leaving the still-alive cells with time to develop mutations, and that should have their toxicities confined to only one or few organs, so that specific protections can be developed and applied.