Hair Today, Gone Tomorrow
Learning to deal with hair loss, flying wigs & rollercoasters.

By Kathleen Wildasin

When Cindy Breed learned 41 months ago that she had ovarian cancer, she was so shocked that she couldn’t cry, but when the doctors told her that the proposed chemotherapy would cause hair loss, she sobbed for days.
“The thought of looking in the mirror at my bald head was unimaginable,” recalls the now 41-year-old mother of two. “I knew it would be a daily reminder that I was dealing with a disease that could end my life.”

Many of the 1.3 million Americans expected to be diagnosed with cancer in 2004 will undergo chemotherapy—treatments that in general target rapidly dividing cancerous cells. But some healthy cells, including those being formed in the bone marrow and those of the gastrointestinal tract, reproductive system, mouth and hair follicles, also divide rapidly, and they too may succumb to the effects of cytotoxic agents. The side effects that may accompany chemotherapy, of which hair loss is often the most dreaded, are the result of the destruction of normal noncancerous cells.

Hair Loss: An Unsolved Problem

The degree, pattern and timing of chemotherapy-related hair loss vary among patients, as do the changes that may occur during hair regrowth.
“The phase of cell division affected by a chemotherapy drug, the dose of the drug, and the treatment schedule determine whether hair loss is complete or partial or whether it occurs at all,” says Ruth O’Regan, MD, director of Clinical and Translational Breast Cancer Research, Winship Cancer Institute, Emory University, Atlanta.

According to Dr. O’Regan, hair loss on the scalp can be a gradual process of thinning or it can happen suddenly—in large clumps and all at once. Hair on the face (even nasal hair, eyebrows and eyelashes), arms, legs and in the pubic area is not immune to the effects of chemotherapy and can be lost at any time during treatment, she says
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Some drugs like Adriamycin^® (doxorubicin), Taxol^® (paclitaxel) and Taxotere^® (docetaxel) may cause profound hair loss, whereas Cytoxan^® (cyclophosphamide) and Gemzar^® (gemcitabine) usually have an intermediate effect (see sidebar, page 39). Vincristine, Navelbine® (vinorelbine) and 5-FU, among others, often cause little or no hair loss, says Christopher E. Desch, MD, research director of the Virginia Cancer Institute in Richmond.

Hair loss sometimes starts with a “tingling feeling” as the first strands come out and can begin as soon as three weeks after the first treatment, Dr. Desch explains.

“Patients on weekly chemotherapy may experience delayed hair loss because individual drug doses are lower,” he says, “and some patients experience a little hair regrowth during the latter part of chemotherapy itself.”

Suggestions for hair and scalp care during chemotherapy include the use of soft hairbrushes, mild shampoos and conditioners and low heat while drying the hair. Dying, perming and relaxing the hair should be avoided during treatment.

The prescription for dealing cosmetically with hair loss on the scalp is straightforward: Patients should do whatever feels most comfortable, from covering the head with scarves, caps, turbans, hairpieces or wigs to simply leaving it bare.

According to Dr. Desch, hair usually begins growing back at a normal rate within a few weeks after the end of chemotherapy, and using a product like Rogaine, which is recommended for chronic age-related hair loss, is unlikely to speed up growth in cancer patients undergoing chemotherapy.

“Although the color and character of the hair may initially differ from its prechemotherapy condition, it typically returns to normal within six months or one year,” he says. “Patients who want to color their hair as it returns should not be discouraged from doing so.”

Preventing Hair Loss

Strategies to retard, reduce or prevent hair loss caused by some drugs are generally ineffective. Cooling the scalp with ice or gel packs and tying the head with a tourniquet have been used in an attempt to reduce blood flow to the scalp and thus decrease the amount of cytotoxic agent reaching the hair follicles. Both strategies are uncomfortable, and the latter is potentially dangerous because pressure caused by lengthy occlusion could damage facial nerves, and the areas of the scalp and face protected from chemotherapy could later become sites of metastases.

Over time, a variety of pharmacologic agents have failed to solve the problem of chemotherapy-related hair loss, but a team of researchers at Boston University Medical Center has recently produced some promising results.

Using a mouse model to evaluate the effect of the parathyroid hormone-related peptide receptor antagonist PTH (7-34) on hair loss induced by the chemotherapy agent Cytoxan, the group found that mice receiving PTH (7-34) had more rapid hair regrowth and more viable hair follicles than those receiving chemotherapy and placebo. The finding prompted the U.S. Food and Drug Administration to allow the use of PTH (7-34) in human phase I/II clinical trials for the prevention of chemotherapy-related hair loss and the acceleration of hair regrowth in breast cancer patients.

In addition, some chemotherapy agents, such as Herceptin^® (trastuzumab), Rituxan^® (rituximab) and Iressa^® (gefitinib), are now being used that do not cause hair loss because they are “targeted” directly at the cancer cells and thus have no adverse effect on hair follicles.

For Breed, hair loss began 17 days after receiving her first infusion of Taxol and was fairly complete within a day or so, although in many patients, hair will fall out more gradually and may not completely fall out despite many rounds of chemotherapy.

The sudden hair loss caused her head to feel bruised for about a week. Many patients do complain of tingling and other sensations on their scalp as their hair begins to loosen and fall. But for Breed, a simple paste of baking soda and water brought effective relief.

“I had my husband shave off the few strands of hair that were left so I could glue a wig to my head, which worked for a while—that is, until a 100-foot drop on the Legoland rollercoaster caused it to fly off into oblivion,” she says.

Even though her hair at the time was only one-half inch long, the event marked the end of her wig-wearing days.

“I would have liked to have worn it another couple of months, but it was not worth the embarrassment. Besides, my short curly hair looked like one of those new vogue haircuts, so I was able to pull it off as a trendy do.”

Breed recalls that regrowth began about three weeks after her last treatment and her hair, which came back in its prechemotherapy color and form, grew at a normal rate. After recently beginning a second round of chemotherapy for recurrence of ovarian cancer, she has already lost 50 percent of her hair from Hycamtin^® (topotecan) and expects complete hair loss with an upcoming regimen that will include Taxotere^® (docetaxel).

“I play tennis when I can, meditate and focus on my young daughters and husband,” Breed says. “Mostly, I think I’m too busy to dwell on the cancer.”

A Tale of Two Women

Terry Freeman and Pam Garner met a year ago at a music therapy class for cancer survivors.

Freeman, 69, has battled breast cancer for more than 25 years and describes herself as a “chronic cancer patient.” Now in remission, Garner, 55, was diagnosed with breast cancer in 2002. Together, their stories illustrate not only the variable nature of the process of hair loss caused by chemotherapy, but also coping strategies for dealing with its emotional ramifications.

Freeman’s ordeal began in 1977 when she underwent chemotherapy with methotrexate, Cytoxan and 5-FU after surgery for breast cancer. After one month of treatment, she lost half her hair in big clumps. But surprisingly, she says, a second round of chemotherapy in 2001 to treat a new breast tumor that had metastasized to the lungs resulted in 75 percent hair loss, this time in a gradual manner, even though the same three drugs were used.

“I still had enough hair during the first session that I didn’t need to cover my head, but during the second session, as my hair kept getting thinner, I wore colored baseball caps and bandanas, even a wig for about six months,” Freeman says. “The wig was beautiful, but uncomfortable, and I was always aware of its presence. At times, I felt that people were looking at me and thinking, ‘She’s wearing a wig. I wonder if she’s got cancer.’”

In 2001, while losing her eyebrows and body hair, Freeman turned to the American Cancer Society’s Look Good—Feel Better program (www.lookgoodfeelbetter.org). “It was a wonderful group of professionals, and the whole experience was a real confidence boost,” she says. “I learned about makeup application and how to use an eyebrow shaper to fill in the eyebrows that I’d lost during treatment.”

Freeman didn’t have complete hair loss during either round of chemotherapy, and her hair regained much of its normal thickness within two months of completing each treatment. “It may now be even more manageable than it was before, which was one of the benefits of chemotherapy,” she quips.

Garner learned she had breast cancer just two weeks before her husband’s scheduled bone marrow transplant (see “Inside Stem Cells,” page 40). “Once diagnosed, I asked my team of doctors how I could be treated and still have the flexibility to go back and forth to the City of Hope, where my husband was having his transplant. Although initially the plan was to do surgery first, the doctors opted to do chemo in hopes of reducing the breast mass, a schedule that enabled me to make the two-hour drive to the City of Hope on a regular basis.”

Hair loss for Garner began within two weeks of the first cycle with Adriamycin^® (doxorubicin) and Cytoxan. When hair started falling out in clumps, she shaved her head. “This was not a traumatic experience for me because I’d already seen my husband go through it and knew what to expect,” she says.

Although hats, caps and turbans became part of her wardrobe, especially in the winter, she “didn’t bother” with a wig, and, while visiting the City of Hope, she often left her head completely uncovered.

“I fit in with half of the folks walking around there and rather liked being bald,” she says. Garner recalls that her hair began growing back a few weeks after the end of chemotherapy and it grew back curlier, softer and darker than its prechemotherapy condition. In a year’s time, it was back to normal, she says.
Even though severe hair loss was expected during a postsurgery round of chemotherapy with Taxotere, Garner experienced only slight thinning on the scalp and did not lose any body hair.

In addition to using music as a coping mechanism, Garner and Freeman also participated in the same stress reduction class. Garner now attends water aerobics and nature walking classes and Freeman practices yoga, visualization and meditation.

One year after her surgery, Garner averaged 20 miles a day in the 2003 Breast Cancer 3-Day Walk in San Diego. “What a better way to say, ‘Cancer, go take a hike.’”