Persistent Alopecia and Docetaxel – Low Incidence, High Impact

Conversation led by Shirley Ledlie with Dr Bevin Bhoyrul, Dr Albane Lhuillier and Dr Dominique Spaeth, on Persistent Alopecia and docetaxel regimens. April 2022

While persistent chemotherapy-induced alopecia (PCIA) may not affect a huge number of patients, it has an incredible impact on the quality of life of those patients who live with long term alopecia. A condition which can impact as many as 10-30% of adult breast cancer survivors, is often observed to be dismissed by physicians, or patients feel they have not been adequately educated on the potential risk. Given that there is currently no consistently effective treatment for PCIA, and that scalp cooling has been shown to be an effective preventative measure, can and should scalp cooling become a standard of care with docetaxel regimens?

"PCIA is a reminder of my breast cancer diagnosis. When I see my reflection, I’m looking at myself sat in the chemo chair, shaking while the nurse tried to find a vein. I see myself with my head down the toilet, or with my fingernails dropping out. I hear the word of my oncologist telling me my hair will never fully grow back. Losing my hair meant saying goodbye to my femininity. I felt like a freak"

Shirley Ledlie, Patient Advocate living with PCIA
  • Persistent chemotherapy-induced alopecia occurs in a predicted 10%-30% of patients receiving taxanes, usually docetaxel with a cumulative dosage of over 400mg/m2 
  • PCIA is defined as the absent or incomplete regrowth of hair 6 months after the completion of chemotherapy
  • While hair density can be improved, there is no known cure for the condition
  • Scalp cooling has been shown to mitigate the risk of persistent alopecia with docetaxel regimens

It is predicted that persistent alopecia is under reported with patients being reluctant to come forward. Clinicians are also quick to dismiss the risk of persistent alopecia with it being low and therefore not something to be concerned with, but patients are becoming increasingly aware of and educated about the risks through the work of organizations such as A Head of Our Time. If it is a patient concern, then it should be a clinician’s concern, as the implications of persistent alopecia can be devastating and life changing. We understand the psychological impact that chemotherapy-induced hair loss can have, and PCIA means a compromised quality of life as a constant for the rest of a patient’s life.

Research shows that the use of scalp cooling can mitigate the risk of persistent alopecia with docetaxel, with cooling preventing irreversible damage to hair follicle stem cells. So, the question remains, why is scalp cooling not a standard of care for high dose docetaxel regimens that can cause persistent alopecia? On top of this, hair retention rates are high with docetaxel, so the patient can expect the short-term benefit of a significant reduction in hair loss during chemotherapy and the long-term benefits of the prevention of persistent alopecia.   

While the use of docetaxel is being reduced and even replaced in countries such as France, it is important to note that PCIA has been seen with drugs including cyclophosphamide, etoposide, and paclitaxel, with taxanes being eight times more likely to be associated with persistent alopecia.  

‘I felt guilty because I was not enjoying my life after cancer’ – Shirley Ledlie, Patient Advocate

Recent research has looked at persistent alopecia from a dermatological perspective, and has found that the trichoscopic features are indistinguishable from androgenetic alopecia – increased vellus hairs, predominant single-hair follicle units, and prominent hair follicle miniaturization. Treatments that have proven to be effective for androgenetic alopecia, such as minoxidil and antiandrogen therapy, did show some level of improvement in more than half of PCIA patients studied, but it required treatment for over 2 years and only produced slight improvements. 

Prevention should always be the priority, and with scalp cooling providing such an effective way of not only preventing long-term alopecia, but also providing the minimization of short-term alopecia, the argument is that clinicians need to be doing more to make scalp cooling a standard of care, particularly with high dose docetaxel treatments. Persistent alopecia could and should become a side effect of the past. Low incidence is not an excuse to not take PCIA seriously, as even one patient living with persistent alopecia where it could have been prevented, is one person too many.  

Bhoyrul B, et al. Clinicopathologic Characteristics and Response to Treatment of Persistent Chemotherapy-Induced Alopecia in Breast Cancer Survivors. JAMA Dermatol. 2021;157(11):1335–1342.

Martín M, et al. Persistent major alopecia following adjuvant docetaxel for breast cancer: incidence, characteristics, and prevention with scalp cooling. Breast Cancer Res Treat. 2018 Oct;171(3):627-634.

Stoehr JR, et al. Permanent chemotherapy-induced alopecia: awareness and attitudes among health care providers. Support Care Cancer. 2020 Jun;28(6):2887-2890.

Betticher DC, et al. Efficacy and tolerability of two scalp cooling systems for the prevention of alopecia associated with docetaxel treatment. Support Care Cancer. 2013 Sep;21(9):2565-73.