Persistent Chemotherapy-Induced Alopecia, Related Distress More Common in Asian Women With Breast Cancer

Significant racial and ethnic disparities were observed in both the incidence and psychological effects of persistent chemotherapy-induced alopecia (PCIA) among women with breast cancer, with Asian women experiencing the greatest burden, according to a study recently published in JAMA Network Open.¹

Evidence Gaps Remain in Understanding Racial and Ethnic Differences in PCIA

CIA is a common adverse event among patients receiving chemotherapy and is often considered temporary.² However, a subset of patients experience PCIA, defined as incomplete or absent regrowth of scalp hair that persists for months or years following treatment.¹

Although the hair shaft is the same across all races and ethnicities, hair structure varies substantially, with Asian women tending to have thicker individual hair shafts but lower follicular density. Meanwhile, Black women often have tightly coiled hair with curved follicles, and non-Hispanic White women typically have intermediate follicular density with thinner, less pigmented hair. The researchers highlighted that these inherent biological differences may contribute to variation in follicular vulnerability and regrowth following chemotherapy.

Despite this, existing PCIA studies have largely been conducted in racially and ethnically homogenous populations, limiting generalizability. Additionally, PCIA-related psychological distress has rarely been compared across racial and ethnic groups using harmonized measures.

To address these gaps, the investigators conducted a prospective, multinational cohort study of patients with nonmetastatic breast cancer receiving cytotoxic chemotherapy, following participants from baseline through 12 months after treatment completion. The study’s primary outcome was PCIA incidence among Asian, Black, Hispanic or Latino, and non-Hispanic White women, with secondary outcomes including changes in their hair density, hair shaft thickness, and alopecia-related distress.

Findings Show Racial and Ethnic Variation in PCIA Incidence and Alopecia-Related Distress

The primary outcome was evaluated through standardized trichoscopic assessments. Meanwhile, the researchers measured secondary outcomes using the Chemotherapy-Induced Alopecia Distress Scale (CADS), a tool consisting of 17 items, with responses based on a 4-point Likert scale. The total CADS score was calculated as the sum of all response scores, ranging from 0 to 51, with higher scores indicating higher distress levels.

The researchers analyzed data from 2 cohorts: the Chemotherapy-Induced Hair Changes and Alopecia, Skin Aging and Nail Changes in Women With Non-Metastatic Breast Cancer (CHANCE) prospective cohort study conducted in the US and the CHANCE Korea twin cohort study performed in South Korea. These studies quantified PCIA incidence in women with breast cancer receiving cytotoxic chemotherapy and endocrine therapy, with the American study conducted at Memorial Sloan Kettering Cancer Center and the South Korean study taking place at Samsung Medical Center.

In the US CHANCE cohort, 226 patients were enrolled and underwent baseline hair assessment. Of these, 175 (77.4%) completed the 12-month follow-up period and were included in the primary analysis. Regarding the CHANCE Korea cohort, 146 patients received chemotherapy and completed baseline assessment, of whom 129 (88.4%) completed the 12-month follow-up. The researchers combined the cohorts and evaluated 304 patients who received chemotherapy and had complete 12-month follow-up data.

The included patients had a mean (SD) age of 50.3 (10.6) years. Regarding race and ethnicity, the cohort consisted of 159 (52.3%) Asian women, 108 (35.5%) White women, 20 (6.6%) Black women, and 17 (5.6%) Hispanic or Latino women.

At baseline, Asian women had the greatest mean (SD) hair thickness (83.2 [13.4] μm); it was significantly higher than that of Hispanic or Latino (74.6 [9.6] μm), Black (72.8 [9.0] μm), and White (70.4 [10.5] μm) women (P < .001). However, Asian women had the lowest mean (SD) hair density (136.2 [27.6] hairs/34.34 mm² at ×50 magnification), while White women had the highest (190.1 [43.0] hairs/34.34 mm), followed by Hispanic or Latino (174.4 [50.8] hairs/34.34 mm) and Black (130.1 [50.9] hairs/34.34 mm) women (P<.001). Conversely, based on the CADS scale, baseline CIA distress scores were comparable across groups, with no significant differences (P = .58).

At follow-up, PCIA incidence was highest in Asian women (n = 59; 42.1%), followed by White (n = 24; 22.2%), Black (n = 2; 10.0%), and Hispanic or Latino (n = 1; 5.1%) women. Similarly, Asian women had the greatest increase in CADS scores compared with White women, particularly in the emotional (adjusted mean difference, 1.88; 95% CI, 0.92-2.95) and activity-related (adjusted mean difference, 1.55; 95% CI, 0.58-2.52) domains.

Findings Highlight the Need for Multidisciplinary, Multiethnic PCIA Research

The researchers acknowledged their limitations, including that the sample sizes for Black and Hispanic or Latino participants were relatively small, limiting the precision of PCIA risk estimates for these groups. Also, causality cannot be inferred due to the study’s observational design. Nonetheless, they expressed confidence in their findings and used them to suggest future treatment strategies and research directions.

“Addressing PCIA requires an integrative, interdisciplinary approach that acknowledges both the molecular and meaning-centered aspects of hair loss,” the authors concluded. “Future studies should validate these findings through large-scale, multiethnic prospective cohorts with harmonized clinical, genetic, and psychosocial data collection to better inform prevention and support strategies.”

References

1. Kang D, Kraehenbuehl L, Lee H, et al. Racial and ethnic disparities in persistent chemotherapy-induced alopecia among women with breast cancer. JAMA Netw Open. 2026;9(1):e2549146. doi:10.1001/jamanetworkopen.2025.49146
2. Lemieux J, Maunsell E, Provencher L. Chemotherapy-induced alopecia and effects on quality of life among women with breast cancer: a literature review. Psychooncology. 2008;17(4):317-328. doi:10.1002/pon.1245