Endocrine Therapy–Induced Alopecia in Patients With Breast Cancer

Abstract

IMPORTANCE Endocrine therapy-induced alopecia (EIA) has been anecdotally reported but not systematically described. OBJECTIVE To characterize EIA in patients with breast cancer. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 112 patients with breast cancer, diagnosed with EIA from January 1, 2009, to December 31, 2016, the patients were examined at the dermatology service in a large tertiary care hospital and comprehensive cancer center. MAIN OUTCOMES AND MEASURES The clinical features, alopecia-related quality of life (QoL), and response to minoxidil of EIA in patients with breast cancer were assessed. Data from the Hairdex Questionnaire was used to assess the impact of the alopecia on patients QoL. Higher score indicates lower QoL (0-100 score). Efficacy of minoxidil was measured at 3 or 6 months by a single-blinded investigator through standardized clinical photographs of the scalp. RESULTS A total of 112 female patients with breast cancer were included (median [range] age, 60 [34-90] years). A total of 104 patients (93%) had standardized clinical photographs; of these, 59 patients (53%) had trichoscopy images available at baseline, and 46 patients (41%) were assessed for response to minoxidil. Alopecia was attributed to aromatase inhibitors in 75 patients (67%) and tamoxifen in 37 (33%). Severity was grade 1 in 96 of 104 patients (92%), and the pattern was similar to androgenetic alopecia. The predominant trichoscopic feature at baseline was the presence of vellus hairs and intermediate-and thick-diameter terminal hair shafts. A negative impact on QoL was reported, with a higher effect in the emotion domain according to the Hairdex score (mean [SD], 41.8 [21.3]; P < .001). After treatment with topical minoxidil, moderate or significant improvement in alopecia was observed in 37 of 46 patients (80%). CONCLUSIONS AND RELEVANCE Endocrine therapies are associated with a pattern alopecia similar to androgenetic-type, consistent with the mechanism of action of causal agents. A significant negative impact on QoL was reported by patients, despite mostly mild alopecia severity.

Persistent Alopecia in a Breast Cancer Patient Following Taxane Chemotherapy and Adjuvant Endocrine Therapy: Case Report and Review of Post-treatment Hair Loss in Oncology Patients with Breast Cancer

“…Various patterns of scalp alopecia have been described in breast cancer patients depending on whether they received chemotherapy, hormonal therapy, or both [ 4 ]. In addition to anagen effluvium, patients receiving only endocrine therapy (aromatase inhibitor or selective estrogen receptor modulator) have been observed to develop a pattern similar to androgenetic alopecia [ 5 ]. Additionally, permanent alopecia has been observed in some patients who received taxane chemotherapy and adjuvant hormonal therapy; in these individuals, the clinical and pathologic findings were similar to either alopecia areata, androgenetic alopecia or both [ 1 , 6 ].…”

“…In comparison, aromatase inhibitors, including anastrozole, exemestane, and letrozole, reduce blood estrogen levels by inhibition of aromatase and are preferred for postmenopausal patients [ 12 ]. These treatments have similar adverse event profiles, which include arthralgias, hot flashes, mood changes, and osteopenia [ 11 - 12 ]; alopecia has also been observed [ 5 ]. Serious cutaneous adverse effects associated with these therapies are rare, but angioedema, erythema nodosum, porphyria cutanea tarda, pseudolymphoma, radiation recall dermatitis, Steven-Johnson syndrome, subacute cutaneous lupus erythematosus, and vasculitis have been observed [ 13 - 17 ].…”

“…In women with breast cancer who developed endocrine therapy-induced alopecia, Freites-Martinez et al observed significant clinical improvement in 80% (37/46) of the patients after treatment with topical minoxidil [ 5 ]. All individuals in this study had not previously received cytotoxic chemotherapy.…”

Permanent Chemotherapy-Induced Alopecia in Patients with Breast Cancer: A 3-Year Prospective Cohort Study

“…At each visit, hair density (number of hairs per cm 2 ) and shaft diameter (μm) were objectively quantified in a reference point on the vertex area by a phototrichogram using a Folliscope (LeadM Corp, Seoul, South Korea). The Folliscope has been used in prior studies of alopecia in patients with breast cancer . The hair shaft diameter of five hairs from the vertex area was measured and averaged .…”

Toxic Side Effects of Targeted Therapies and Immunotherapies Affecting the Skin, Oral Mucosa, Hair, and Nails

“…In a meta-analysis of 35 studies ( n = 13,415 patients) the incidence of all-grade HTIA ranged from 0% with anti-androgen therapies to 25% with selective estrogen receptor modulators (SERMs), corresponding to an overall incidence of 4.4% [ 60 ]. In a retrospective study of the data for 112 patients treated with SERMs/aromatase inhibitors, HTIA was most often (92%) characterized by an androgenic alopecia pattern and low severity grade [ 61 ]. Tamoxifen-induced alopecia is characterized by a reduction in the number of hair follicles [ 62 ].…”