Chemotherapy induced hair loss: social and cultural messages conveyed by how you wear your hair

“If I want to knock a story off the front page, I just change my hairstyle.” — Hillary Clinton. During the 2016 campaign that lasted longer than any other, “hair” was a topic of discussion and comments, almost as often as healthcare. The centrality of hair in all cultures and society is not insignificant.

Outward appearances are often used as a proxy for a person’s social and cultural moorings, and political beliefs. Using these proxies, it is only too common to see people being put in boxes by observers (implicit bias), sometimes with frightening consequences. Hair, is part of one’s outward appearance, and has the potential to influence how one is perceived. In fact hair has been the subject of anthropological research, leading to a greater appreciation of the significance of hair in society.

Because of the importance of hair in society, alopecia, or hair loss, is particularly devastating for women and children: people are accustomed to seeing a bald adult male; not so a bald woman or child. Alopecia can be a consequence of a genetic predisposition to it, or because of medical treatments particularly those for treating cancer. Some chemotherapeutic agents, as well as radiation, result in hair loss that is sometimes short lived, but can also extend for years.

Why do some cancer patients lose their hair?

Apart from a few areas, the human body is covered with hair follicles made up of different types of cells. These cells are some of the fastest dividing cells in the body. The hair follicle is a complex organ as shown in this simplified figure — the hair shaft arises from the follicle and is surrounded by sweat (sebaceous) glands and a reserve of stem cells that go through a

series of steps before they become hair. Depending on the location, the duration of each step of the cycle from stem cell to hair, varies and effectively dictates the length of the hair: for eyebrows, the cycle is about four months, whereas for the scalp it can be four years.

Since a hallmark of cancer is uncontrolled cell division, many drugs that cancer patients receive are targeted to dividing cells. Consequently, other cells that are actively dividing are also targets for these drugs. Hair loss is therefore a consequence of collateral damage from cancer drugs. Radiation therapy also arrests and kills cells that are dividing, resulting in similar hair loss. Once treatment is stopped, the stem cell reserves slowly get back into action, although in some instances damage from these treatments can be so profound that the stem cells are unable to spring back effectively.

The emotional and social cost of chemotherapy induced hair loss is consequential yet not easily calculated, and varies from person to person; the cost is also influenced by the prevailing ethos. There are still places in the world where you will find people who are so fearful of cancer, that they will shun someone with cancer. In such places, a cancer patient is pummeled on yet another level when she experiences hair loss. But despite all this, we have limited ways to stop chemotherapy induced alopecia (CIA).

How can you stop cancer drugs from getting to the hair follicles?

For more than forty years there have been attempts to reduce exposure of the scalp to cancer drugs. The most common method to do this is by cooling the scalp. The logic here is to reduce blood flow to the scalp by drastically cooling it — reduced blood flow will mean smaller amounts of the cancer drug reach the scalp, since these are drugs that are administered intravenously. But scalp cooling has its own set off collateral effects — these include severe headaches and light-headedness; and according to some, the possibility of cancer cells in that area escaping destruction and continuing to multiply. More importantly, the best available cooling system cannot guarantee that all users will not lose their hair — according to some reports, only 5% of study participants had no hair loss. Further, in the US, scalp cooling for CIA is still in a hazy area when it comes to health insurance coverage, with out-of-pocket expenses being as high as $1500 or more per round of chemotherapy. Considering that there is data to show that as many as 8% of patients forego chemotherapy because they don’t want to deal with the devastation of hair loss, it is shocking that insurance companies are reluctant to support the procedure — when they show little hesitation to support drugs for erectile dysfunction.

Other avenues to deal with CIA

In order to conform or maintain one’s social status, there are some unwritten (and in some places, written) rules about how hair should or should not be worn. Likewise, if one wishes to rebel against the status quo, hair can be an excellent megaphone for rebellion. A 2017 BBC documentary, “Hair Care Secrets”, explores the research and technology underlying the hair care industry and tries to tease out why we pay so much importance to the appearance of our hair. With all the social power that comes with hair, it is hardly surprising that the hair care industry’s profit margins grow each year.

The L’Oréal group of companies have the largest global market share, with $27.6 billion in annual sales in 2016, for all hair care and other “beauty products”. In fact, 182 major brands are owned by seven companies (Estée Lauder Companies, L’Oréal, Unilever, Procter and Gamble, Shiseido, Johnson and Johnson, and Coty) and they make their money by promoting their brands in many ways, including manipulating an individual’s insecurities about appearance. In the name of corporate social responsibility, the companies setup foundations and fund programs that include training people to use their products. But the money that goes to these programs is less than 1% of what is spent on advertising and marketing. In 2016, L’Oréal spent more than $8 billion in worldwide marketing and advertising — that’s more than the GDP of The Bahamas ($9 billion).

The number of individuals who suffer CIA is nowhere near the number of people who purchase hair care products made by the seven major companies. Therefore, the bottom line of these companies remains largely unaffected when cancer patients aren’t consuming their hair care products. But wouldn’t it be a novel idea if these companies with their financial, and political clout, would stand up and be counted among those who improve the lives of cancer patients? Organizing fundraising walks, bike rides, and runs to support cancer research; and coloring product containers pink to support breast cancer in October is really more an advertising gimmick for the companies and their products, than anything else. How much of the corporate balance sheet are these companies willing to commit to making a case for access to full insurance coverage for scalp cooling during chemotherapy? Or to research that will improve current technologies for scalp cooling, so that all cancer patients, and not only those with solid tumors benefit? A constant onslaught of advertising and marketing campaigns by these very companies reinforces and enhances social beliefs regarding hair, so it would behoove them to take on the cause of chemotherapy induced alopecia, both at the political and research level. It’s really never too late.

The author experienced chemotherapy induced alopecia when she underwent year long treatment for breast cancer until 2012.

Deepti is a scientist & now, a research analyst at Yale University. She runs Tilde Cafe, a forum to demystify science & make it accessible (