Management of hair loss associated with endocrine therapy in patients with breast cancer: an overview

Abstract

Endocrine therapy-induced hair loss (ETIHL) associated with aromatase inhibitors and tamoxifen treatment is currently mostly reported but remained an unresolved therapeutic issue in patients with breast cancer (BC) since the number of studies regarding the management is limited in literature. Herein we investigated the possible causes of this clinical problem and its relation with endocrine therapies widely used for BC survivors and made some modest practical recommendations in light of the literature review in order to provide an optimal management. On the basis of literature findings, common causes of hair loss apart from endocrine therapies should be investigated with an initial evaluation workup and then should be corrected, if observed. Treatment with topical 5-alpha reductase inhibitors and supplementation of Vitamin C and omega-3 fatty acids are likely appeared to be the most appropriate treatment agents for ETIHL without causing an adverse effect on BC prognosis. However, more prospective, randomised, placebo-controlled studied are required in order to confirm our results and also identify the clinical effects of this problem on patients with BC.

Aromatase inhibitor–induced hair loss in two adolescents

“…When endocrine receptor activation and pathway signaling are blocked, such as with the use of aromatase inhibitors, dihydrotestosterone levels increase secondary to enhancement in the activity of 5α-reductase, contributing to the induction of alopecia in those receiving the medication. 9 Due to the dearth of published data on childhood and adolescent AGA, it is difficult to assess the prevalence or incidence of androge- 11,12 To our knowledge, hair loss has not been documented from treatment of aromatase inhibitors in the pediatric population, although it has been reported with the use of triptorelin, a long-acting gonadotropin-releasing hormone used to treat idiopathic central precocious puberty. 13 Our patients developed signs of androgenetic alopecia within one year of treatment with anastrozole for idiopathic short stature.…”

“…It is important to ascertain patients’ expectations regarding therapy and advise them on various possible treatment options for endocrine therapy‐induced hair loss (ETIHL). Currently, minoxidil, a direct‐acting peripheral vasodilator, is the standard of care for chemotherapy‐induced hair loss 9,16 . Other treatments being explored for ETIHL include combining endocrine therapies with mitotane and ketoconazole shampoo to decrease ovarian or adrenal androgenic hormones, folic acid, vitamin C, vitamin D, vitamin E, omega‐3 fatty acids, and folic acid 9 .…”

“…Estrogens and androgens are also critical hair growth modulators. When endocrine receptor activation and pathway signaling are blocked, such as with the use of aromatase inhibitors, dihydrotestosterone levels increase secondary to enhancement in the activity of 5α‐reductase, contributing to the induction of alopecia in those receiving the medication 9 …”

The Potential Role of Nutraceuticals as an Adjuvant in Breast Cancer Patients to Prevent Hair Loss Induced by Endocrine Therapy

“…SERMs display mixed properties due to their individual cell-specific activity ( Figure 1 ). While tamoxifen remains the gold standard for treatment of ERα-positive breast cancer in premenopausal women, aromatase inhibitors, including anastrozole, letrozole and exemestane, that suppress estrogen biosynthesis are the preferred option following menopause and in tamoxifen-resistant patients [ 35 ]. However, while tamoxifen only blocks ERα receptors in tissues where it acts as an antagonist (e.g., breast), due to tissue selectivity, it may have beneficial effects in other tissues where it acts as an agonist, e.g., bone.…”

“…Because ETIHL negatively affects sociocultural status and quality of life, it is a major problem and remains a therapeutic challenge in patients with breast cancer. Supplementation with vitamins (D, E, C, folic acid) and/or omega-3 fatty acids has been a popular adjuvant therapy, often associated in combination with minoxidil [ 35 , 56 ].…”