Redefining the “crown”: Approaching chemotherapy‐induced alopecia among Black patients with breast cancer

For centuries, hair has been critical to how human beings understand racial categories, gender designations, class status, and personal worth. For Black women in particular, hair has been and continues to be deeply tied to ethnic identity. Its history is complex, ranging from the 1960–1970s “Black is Beautiful” movement that popularized the Afro and other non‐Eurocentric styles as symbols of self‐ determination and political protest, to Black hair being denigrated in schools and workplaces. Black hair has even necessitated legislation to protect its expression. In light of this contentious history, Black communities have informally adopted the word “crown” when referring to Black hair in an effort to redefine Black beauty and create a positive cultural consciousness. Hair loss, therefore, can be a devastating experience, perhaps even more so when associated with a breast cancer diagnosis. Research demonstrates that chemotherapy‐induced alopecia (CIA) is associated with low body esteem, low self‐efficacy, and negative coping behaviors related to cancer diagnosis among women, with some declining cancer treatment altogether to avoid hair loss. Although most of the data on CIA include predominantly White cohorts, there is a paucity of research regarding the specific impact of CIA among Black women, who are disproportionately affected by more aggressive disease in which chemotherapy (particularly neoadjuvant chemotherapy) is more likely to be administered. One literature review only showed four studies specifically characterizing CIA outcomes among African American women, with data suggesting that this group may be at higher risk of diffuse, permanent alopecia and may achieve poor results in hair preservation interventions. A qualitative study of 38 Black survivors of breast cancer revealed disturbing implications of CIA, such as hair loss being perceived by participants as more traumatic than the loss of breast tissue and experiencing physiological side effects of illness stemming from the loss of patients' hair, sentiments also echoed by patients in other CIA studies. Perhaps distinctive to Black women were the concerns about the inability to wear wigs that were not designed for Black hair color or textures, with the author highlighting the need for practitioners to better understand such unique psychological effects of CIA on Black women. Given the racial and gendered context of CIA, the aim of this commentary is to illuminate the cultural relevance of Black hair to the breast oncology community and explore how therapeutic options for CIA may uniquely impact Black breast cancer survivors. The extent of CIA can vary by patient based on factors such as drug dose, administration, age, medical comorbidities, nutritional status, and preexisting alopecia. CIA tends to be most profound for patients receiving anthracyclines (such as doxorubicin), taxanes (such as paclitaxel and docetaxel), cyclophosphamide, or etoposide. Although hair regrowth can restart up to 6 months after chemotherapy, the texture and appearance of hair may undergo permanent changes and, rarely, some patients may experience permanent alopecia. Some of these predisposing factors may be more present in