Julie Scott, D.N.P., ANP-B C

Chemotherapy-induced alopecia, or hair loss, is a common side effect of many chemotherapy treatments for cancer. 

Chemotherapy works by targeting rapidly dividing cells, such as cancer cells. However, hair follicles also divide rapidly and are therefore affected by the treatment. As a result, hair loss can occur anywhere hair grows –– on the scalp, face and body. Not everyone who receives chemo will experience hair loss, but for those who do, it can be distressing.

For many people, hair is an important aspect of self-expression and identity, and losing it can be emotionally difficult. As she recalls her experience with chemotherapy for breast cancer, Lauren Thorse remembers that when she was told she would need chemotherapy, “my first thought was that my hair is gonna go.” 

Lauren Thorse says a year after completing treatment, she still "mourns" her long, pre-treatment hair. 

As someone who reports struggling for years with self-confidence, Thorse, of Naperville, Illinois, found the impending hair loss upsetting. Having always had long blond hair, seeing it fall out in clumps and finding it around the house led her to decide to shave it. With the support of her father, and her mother and sister via FaceTime, her husband shaved her hair off.

After finally coming to terms with losing her hair, she then had to wrap her head around the fact that “it’s going to take years to get back to where it was.”

Cancer survivor Jessica Gardner of Youngstown, Pennsylvania, also took matters into her own hands when she began losing her hair from chemotherapy. After being diagnosed with breast cancer while 33 weeks pregnant and undergoing a bilateral mastectomy not long after having a cesarean section, she felt that she wanted to have control over something — and that was her hair loss. While livestreaming the shaving of her head, she felt as if she was getting some of her power and control back.

Once their hair was gone, both Thorse and Gardner felt frustrated over the lack of resources that were available to women their age, in their early 30s, with young children. They found that many of the resources were for older women and didn’t quite meet them where they were in life. 

Thorse recalls, “I felt like the wigs I was directed to were more for older women.”

Jessica Gardner took back control of her hair loss by livestreaming as she shaved her head, then found a patient support group. 

Because Gardner found local support groups difficult to connect with, she created the group Cancer Is a Mother on Facebook. She found that this was a way to do something positive with her cancer diagnosis. “It was something I needed to do personally to feel better about cancer and where I was as a survivor.”

Hair loss can be gradual or sudden, and it can begin within a few weeks of starting chemotherapy treatment.

Some patients may experience thinning of the hair, whereas others may experience complete baldness. In some cases, hair may only thin or fall out in certain areas, creating patchy hair loss. This is most often temporary, and the hair will grow back once chemotherapy treatment is completed. 

However, in rare cases, some patients may experience long-term or permanent hair loss. The risk of either of those is generally low, but it can depend on the type and dose of chemotherapy used. Certain chemotherapies, such as taxanes, are associated with a higher risk of long-term or permanent hair loss.

Now that a full year has gone by since completing chemotherapy, Thorse states that although her hair is growing, she doesn’t look like she used to. “Every now and then I do mourn for myself if I do see a picture. It’s been a year, but I still have a long way to go.”

Chemotherapy isn’t the only cancer treatment that can affect hair. Hormone therapy for cancer treatment can target hormones that help cancer cells grow, such as estrogen and progesterone. It can be used to block the production of these hormones, or block the receptors that respond to them, or lower their levels. This changes the balance of hormones in the body and causes hair thinning. This also causes hair follicles to shrink, leading to thinner, weaker hair.

Lisa Opalweski, of Fond du Lac, Wisconsin, has experienced hair loss multiple times during her cancer journey. Initially diagnosed with breast cancer in 2012, she notes, “Yes, I knew I was going to lose my hair; yes, I was going to run around bald for a while. I knew it was going to come back.” 

After being diagnosed with metastatic cancer in 2019, she has been treated with hormonal therapy and targeted therapy. “I used to have extremely thick, curly hair. Now I have baby thin hair.”

temporary solution for hair loss. Many cancer centers and support groups have resources for obtaining wigs or hairpieces at little or no cost. However, there are now ways to help manage hair loss through scalp cooling. Cooling the scalp during chemotherapy treatment decreases blood flow to the scalp and reduces the amount of chemotherapy drugs reaching the hair follicles. By reducing the amount of chemotherapy that reaches the hair follicles, patients experience less hair loss.

According to the results of one study led by Dr. Julie Nangia, a breast oncologist and an assistant professor of medicine at the Lester and Sue Smith Breast Center and Dan L Duncan Comprehensive Cancer Center at Baylor College of Medicine in Houston, women receiving chemotherapy for early-stage breast cancer were enrolled in a study to evaluate the effectiveness of scalp cooling on hair loss. Of those who underwent scalp cooling, 50.5% had some preservation of their hair after four cycles of chemotherapy. In those who did not use scalp cooling, no one experienced hair preservation.

There are currently a couple of ways to cool the scalp. One way is through the use of cold caps, which uses tight-fitting caps placed on the head to cool the scalp during chemo- therapy infusion. The caps are stored in a special freezer and must be changed throughout the infusion to keep the scalp at a sufficiently cold temperature. In order to successfully use the caps, a patient will need to have help to change the caps at the instructed intervals during treatment.

Another method of scalp cooling is through a device that circulates coolant through the cap to keep the scalp at a consistently cool temperature. The hat is placed once at the beginning of treatment and the coolant will continue to keep the temperature consistent. 

According to Dr. Nangia, cooling the scalp starts 30 minutes before chemotherapy and the cap continues to be worn until 30 to 90 minutes after chemotherapy has been completed. 

It is also important to practice good hair care with scalp cooling therapy. This can include using a gentle shampoo, avoiding heat styling tools, and being gentle when combing or brushing the hair.

Dr. Nangia notes that the biggest barrier to scalp cooling is the cost. If insurance does not cover the therapy, out-of-pocket costs can be over $2,000. She states that the National Comprehensive Cancer Network, which provides guidelines for cancer treatment and supportive care, has added scalp cooling to these guidelines as a method to be considered for those who may experience chemotherapy-induced alopecia. 

With this recommendation from the network, Dr. Nangia hopes that insurance companies will start covering the cost of this therapy so more patients can benefit.

The rate of hair regrowth can vary for each patient, but typically hair starts to regrow within a few weeks to a few months after completing chemotherapy treatment. Regrowth may be slow at first, but it should become more rapid over time. It can take several months to a year for hair to fully regrow and regain its previous texture and color. In some cases, hair may not fully regrow or may regrow with a different texture or color.

Chemo curls, also known as “chemo waves,” is a term used to describe the changes in hair texture that some patients experience after chemotherapy. The term refers to the curls, waves or kinks that can develop in the hair as 

it regrows. This can be caused by the chemotherapy treatment and the changes in the hair

structure. It is not exclusive to scalp hair and can occur on hair all over the body. The new hair growth is usually soft and thin at first, and it may take several months for the hair to return to its pre-treatment thickness and texture. 

Some people may experience complete regrowth of their hair, whereas others may have patchy or thin hair growth. It also might take one to two years for hair to appear as it was before chemotherapy, and this can vary from person to person. Overall, hair growth after chemo is a gradual process, and it can take time for hair to fully recover.

Many members of the health care team are involved during cancer treatment. However, one area that is often overlooked and underutilized during this time is dermatology. 

Dr. Adam Friedman, professor and chair of dermatology at George Washington University in Washington, D.C., knows what dermatologists can offer patients experiencing hair loss during cancer treatment, but they are not often a part of the cancer experience.

He suggests prevention of hair loss through scalp cooling may offer the best results if someone is experi- encing complete hair loss, but there are other options for those with thinning hair that may be helpful. Applying topical minoxidil to the scalp can keep the hair in a constant state of growth. Friedman notes that it must be used consistently for best results and can be difficult to apply. 

He cautions against the use of supplements unless they are specifically approved by the health care team. Some supplements, such as biotin, can interfere with some blood tests, and may not
be safe for some patients to use. He also notes that the off-label use of Latisse (bimatoprost) can be helpful for regrowth of eyelashes and eyebrows after chemotherapy.

One of the most important things voiced by cancer survivors is that they want hair loss to be a topic that is brought up and discussed, and not glossed over, during visits. Megan Harman, FNP-C, with SSM Health in Lake St. Louis, understands this. She understands that hair loss can be a harsh reality the patient with cancer has to live with. It can be difficult for patients to fully prepare mentally and emotionally for hair loss until it happens. When talking with patients during this time, she often directs them toward various resources
and allows them the time to voice their feelings about their situation.

It is notable that much of the research about alopecia focuses on breast cancer survivors in comparison with other cancer survivors. One reason is that breast cancer is the most common cancer among women and the second most common cancer overall, so a large number of patients undergo chemotherapy treatment for breast cancer. Additionally, hair loss is a common and highly visible side effect of chemotherapy treatment, and it can have a significant impact on a person’s quality of life. Breast cancer survivors, especially women, tend to be more concerned about hair loss due to chemotherapy as hair loss affects their appearance and self-esteem.

Another reason is that breast cancer research has traditionally been well funded, which has allowed for more research to be conducted on the effects of chemotherapy on hair loss in breast cancer survivors. This has resulted in a greater understanding of the mechanisms behind hair loss and the development of new hair loss prevention and treatment methods specifically tailored for patients with breast cancer.

For more news on cancer updates, research and education, don’t forget to 

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Many survivors see significant hair changes during cancer treatment, leaving a difficult reminder when they look in the mirror. 

Managing Chemotherapy-Induced Hair Loss

About a week after his wedding in June 2021, 31-year-old Andrew Garcia received a diagnosis of rhabdomyosarcoma (a rare cancer that forms in soft tissue) after what was initially an evaluation of a cut on his hand. After the diagnosis came a whirlwind of discussions about treatments he would need, including surgery, chemotherapy and radiation.

“It felt like life stopped for me,” he recalls. “I didn’t feel like there was much I could do.”

Before treatment started, his oncology team discussed fertility preservation and he was referred to a fertility clinic. 

After cancer treatment left Andrew Garcia struggling with fertility, he and his wife, Cassie, have spent over $20,000 on the in vitro fertilization process. 

“At that time, fertility was the last thing on my mind,” Andrew says. “I didn’t realize that chemo could make me infertile.”

He successfully completed treatment and continues with routine observation to watch for signs of cancer recurrence. Now he and his wife, Cassie, both of Alexandria, Virginia, are trying to pursue the next phase of their lives — parenthood.

“We grieved the beginning of our marriage,” Cassie shares. “We didn’t get to take a honeymoon yet. The first year he was sick; I was his caregiver, there was work. Ultimately, it has brought us closer together.”

After completing treatment for a cancer diagnosis, survivors may feel they have moved beyond one of the most difficult seasons of life. However, for many, the end of treatment marks the start of a new struggle: the path to parenthood. A cancer diagnosis and subsequent treatment can leave long-lasting side effects, making conception a challenge, and for some survivors, an unexpected consequence. 

Many survivors struggling with fertility feel like cancer has taken one more important thing away from them — a sentiment echoed by the Garcias on their journey to parenthood.

Fertility can be affected by many factors including type of treatment received, baseline fertility status, age and other medical conditions. The exact number of people living with infertility due to cancer treatment may never be known but has become more common with cancer cure rates increasing over the years.

Cancer treatments do not universally cause infertility, but many can affect fertility. At the time of diagnosis, a patient may not even be thinking about fertility, or how this health status change could affect the prospect of parenthood. This is especially true in instances of aggressive cancer that requires quickly starting chemotherapy.

Surgery, radiation, chemotherapy and hormonal treatments can lead to infertility for men and women, depending upon their diagnosis. For example, if surgical removal of reproductive organs, such as the ovaries, uterus, cervix or testicles, is required, fertility can be permanently affected. 

Infertility can also result from radiation treatments provided in the pelvic region.

Additionally, chemotherapy medications or hormonal treatments may temporarily or permanently stop egg production and induce menopause in women. In men, chemotherapy is known to stop or reduce sperm production.

Unfortunately for many, there is no discussion of fertility before treatment starts, and it becomes something else for which those living with cancer, as well as survivors, must advocate for. 

 should be happening from the beginning and continue through treatment and survivorship. 

Adriana Sosa, 41, of Castro Valley, California, recalls only a brief discussion about fertility when she received her breast cancer diagnosis in 2015. At the time of her diagnosis, she had a 3-year-old son. 

“My oncologist was worried because I was so young and had just one child,” she says. “He talked about, what were my plans for the future? Did I want more kids? He was asking questions I didn’t know how to answer.” 

She recalls that she was more focused on surviving breast cancer for the sake of her son. “I have to be fine for him. If I can’t have kids again, so be it.”

Adriana Sosa was so focused on surviving cancer for her son, Alex, she didn’t ask many questions on preserving fertility for the future.

Sosa began treatment, which included hormone therapy and surgical removal of her ovaries. Her son is now 12, and at times she wishes she had asked more questions about how she could have preserved fertility. 

Her advice to others facing a comparable situation is: “Think out loud. Whatever is in your head, say it. You’re the only one who can advocate for yourself.”

Dr. Pascale Salem, a medical oncologist at SSM Health St. Joseph Hospital in Lake St. Louis, Missouri, makes a point of having conversations about fertility when discussing treatment options with patients. She recognizes the importance of patients being fully informed about what can happen and wants to do her part to support fertility preservation where possible. 

“There is a pressure for people to start chemotherapy as quickly as possible,” she explains. “But there is time to let fertility preservation take place.”

These conversations take place as often as needed for the patient to feel comfortable with the plan and meet directly with experts in this field. She wants patients to have the opportunity to ask questions and have time to seek fertility preservation assistance.

Without adequate conversations between oncologists and their patients, there can be upset and struggles as someone transitions into cancer survivorship and wishes to start a family. 

Jessica Gorman, an associate professor in the College of Public Health and Human Sciences at Oregon State University in Corvallis, states that many young cancer survivors “are unaware that their cancer treatment was going to affect their fertility. They often state that they weren’t well-informed about their fertility options.”

Gorman also discussed the impact infertility has on mental health, especially for women, given societal expectations of motherhood. She says cancer survivors have told her that “the idea of not having kids is as hard as, or even harder, than getting the cancer diagnosis. It’s a huge loss.”

Options for fertility preservation and timing for these interventions can be different for men and women. Depending on the cancer diagnosis, there may not be much time for prioritizing fertility preservation. 

Dr. Akanksha Mehta, a urologist at the Emory Winship Cancer Institute in Atlanta, understands that time is pressing in such situations. She works closely with the Emory Reproductive Center to preserve fertility for cancer survivors.

“When I get a referral, I’ll see that patient as soon as possible. I’ll either see him in person, in the office or with a telemedicine visit. I like patients to understand how the process works,” she says. “Someone needs to continue to follow them even after treatment is done. Many treatments can lower testosterone, and someone needs to follow that as well.”

Mehta’s patients are men, and her approach to fertility preservation includes a recommendation to have one or two sperm deposits frozen for future use. Sperm quality is the best when the sample is collected before starting chemotherapy medications. 

“Fertility should be a consideration from day one,” she adds.

For women, the process is often more complicated and usually requires additional weeks of planning. 

Egg harvesting from the ovaries may be recommended to help preserve fertility. This is typically done with injections of hormonal ovarian stimulation medications. Hormone levels and the number of egg follicles are monitored with regular ultrasounds. When the follicles reach the appropriate size, a trigger shot is administered, allowing the eggs to be released and harvested a few days later. The eggs can then be fertilized with sperm to form embryos for frozen storage, or they can be frozen without being fertilized.

Previously, egg harvesting could take months, as it needed to be timed with the natural menstrual cycle. With newer medications and procedures, the process now takes two to three weeks. 

Although the process is quicker, the cost of the procedure and storing the frozen eggs or embryos can be prohibitive for many patients. Everyone’s financial responsibility can differ, and it can cost tens of thousands of dollars for fertility preservation.

The price tag associated with fertility treatments has been an issue faced by the Garcias. They both have insurance that helps cover the cost of some, but not all, medications and procedures associated with in vitro fertilization (IVF).

“Insurance doesn’t cover everything,” says Cassie. “It covers 50% of the cost of the embryo transfer but doesn’t cover the cost of thawing the embryo. It feels like insurance companies say they cover infertility treatments, but then pick and choose what they want to cover. They don’t cover the cost of moving the embryos from one fertility clinic to another, or the monthly cost of storing the embryos.”

At this time, they have spent over $20,000 on their journey to parenthood.

Additional fertility preservation treatments may be offered, such as surgically moving the ovaries to the side to decrease their risk of radiation exposure (called ovarian transposition), or even removal of ovarian tissue to be frozen and transplanted later when treatment is finished. Ovarian cryopreservation is still experimental, but may be a treatment choice for those who receive diagnoses during childhood.

Maresa King, 35, of Irvine, California, struggled with infertility during and after treatment for breast cancer. She and her husband decided to go through IVF after understanding the effects chemotherapy would have on her fertility. But because she was on disability, only making 60% of her annual salary, they decided to take out a loan to cover the costs.

Maresa King has since given birth to her second child, whom she was told she would only have a 1% chance of conceiving. 

However, her treatment and the cancer were so aggressive that the oncologist only gave her one shot at it. They were able to retrieve 12 eggs; however, she was told the quality was “really bad.” Three were able to be frozen. 

After undergoing IVF treatment, during a six-month break from cancer treatment, two were successful and King was pregnant with twins. 

Unfortunately, due to pregnancy complications, only one lived. 

“After that, the doctor told me, ‘You’re done. You can’t have kids on your own. The possibility of ever having kids on your own is about 1%,” she says. “We counted our blessings and understood that was our only shot.”

But it was not. With a 1% chance, King was able to conceive naturally. Her pregnancy went well, and she has since given birth — however, one lasting side effect she did experience from chemotherapy was shortness of breath.

“I was very shocked and in disbelief that I was actually pregnant. Then anxiety took over because I didn’t believe things would work out and I would go on to have a healthy pregnancy, especially with everything that happened with my first pregnancy. Eventually all I had left to do was have faith and pray that God would allow me to get through it and bring to this world a healthy baby,” King shares.

For some cancer survivors, the path to parenthood may be difficult. There may be multiple options available, though, for those who wish to become parents. In addition to procedures such as IVF, other options can include surrogacy, IVF with donor eggs or adoption.

During this journey, it is important for cancer survivors to be their own advocate. Survivors will need the support of their oncology team not only to treat their disease, but also to live their life beyond cancer while on the path to parenthood.

For more news on cancer updates, research and education, don’t forget to 

Fertility may be affected due to cancer treatment, altering the way survivors move on to their next phase of life — parenthood. 

Julie Scott, D.N.P., ANP-B C

Managing Chemotherapy-Induced Hair Loss

Fertility Discussions Help Cancer Survivors Preserve the Next Phase of Their Life

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