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“I understand that the biggest fear you have about going through chemotherapy is losing your hair. I just want to tell you. You will be fine. Trust me.
I know it’s barbaric. Why don’t we have medicines to treat cancer that will not make you lose your hair in this day and age? Strange, right? But science has its limits. Work is being done on finding such drugs, but we are not there yet. If you Google “forced standing,” a black and white picture of a girl from a couple of hundred years ago pops up who is being forced to stand, by tying her neck and arms with ropes to the ceiling and walls. Her head is slightly slumped over to one side as if she does not want to stand. The caption will inform you that this is actually how clinical depression was treated at that time. Perhaps if someone is depressed and is lying in bed all day, forcing them to stand up would somehow cure depression. When we look at that picture today, it seems like a scene out of a horror movie. Whoever I have shown that picture to has gasped. But at that time, this treatment was likely endorsed by some, if not all, psychiatrist societies of the world. Human history, after all, has no deficit of theories and rituals that were popular at the time but later considered abhorrent.’
Farhan S. Imran is a hematology-oncology physician who blogs at Did I Ask?
He shares his story and discusses his KevinMD article, “To my patient who is going to lose her hair from chemotherapy.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe to the show at KevinMD.com/follow.
Today we welcome back to the show Farhan Imran. He’s a hematology-oncology physician, and he wrote the KevinMD article “To my patient who is going to lose her hair from chemotherapy.” Farhan, welcome back to the show.
Farhan S. Imran: Thank you, Kevin. It’s always good to be back on your show.
Kevin Pho: So we’ll get to the article in a little bit, but just tell me, since we last spoke, how’s everything going with your hematology-oncology practice?
Farhan S. Imran: I think things are going well. During COVID, we went to doing a lot of televisits, but now it’s back in full form. It is very exciting to see the pandemic really coming to the tail end. Slowly the hospital is removing the masking policy in some outside areas, and the masking policy is gone in the community. So those are all very good things. It’s a good feeling to see that.
Kevin Pho: Sure. And I know that we’ve talked several times during the pandemic over the last few years. Now, how have you changed as a physician?
Farhan S. Imran: Well, that’s a very interesting question. As physicians, and I can personally say this, I’ve become more resilient, in the sense that I have more confidence in my profession, because no living person had seen this pandemic. The last real pandemic, the Spanish flu, was in 1918, which is exactly 100 years ago. So anybody who would have been alive would have to have been at least 10 to 20 years of age to remember that, and no living person knew that. So the pandemic was actually very exciting to me professionally, because we deal with epidemics or local diseases, but a disease of this magnitude was the first time we saw it. And then when it hit, there was a big element of nervousness as to how we were going to deal with all of that.
And I don’t want to minimize the number of lives that were lost and the toll it took on the doctors, nurses, and all the other health care professionals. But now we are coming out of it, and it almost looks like the springtime of the pandemic. So I would say more of a resolve, more resilience, and more trust in the science and in the profession. That is how I would sum it up, as I personally came out of this pandemic.
Kevin Pho: Now let’s get on to your KevinMD article. You always share such interesting and wonderful case studies and stories, and this one is no exception. It’s titled “To my patient who is going to lose her hair from chemotherapy.” Now, for those of you who get a chance to read that article, again, just walk my audience through it and share the story of why you decided to write it.
Farhan S. Imran: Sure. So the reason I wrote this, Kevin, is because I have a general hem-onc practice, but I focus more on breast cancer, and part of the treatment that I give is chemotherapy, and chemotherapy has been associated with cancer for the last several decades. I had a number of patients, mostly women, who were just so terrified of going through chemotherapy. And then when I dug deeper into it, I found out that they were not as worried about the things that I was worried about, such as neutropenic sepsis, or neuropathy, or kidney or renal dysfunction, but they were so extremely scared of losing their hair that I wanted to reach into their minds and try to speak with them about how they’re feeling about it, how I understand it, and what I want to say to them.
Of course, a lot of thoughts came to my mind, and not everything can be discussed with each patient at each visit. So I thought I’d put it together as a piece, and I sent it to you. Really, the way I start is to tell the patient, “You know, you should be OK.” And it’s almost like, I wouldn’t say an apology, but in a way I’m telling the patient, “You know, bear with me. This is the best that we have right now.”
Because if you look at the history of medicine, I say in the article that if you Google, and anybody who’s watching this podcast, I encourage them to Google “forced standing,” when you Google “forced standing,” if you click on an image, a picture of a girl in her teenage years comes up. She is in a room where she is forced to stand, with some ropes tied to her arms and to her neck, and she’s being forced to stand. Initially, you don’t realize what it is, but then you read the caption. Now, I don’t know how verified that information is, but I wouldn’t be surprised if it’s true, because the history of medicine is full of examples of treatments like that. This was just about 100 or 200 years ago, when depression was treated like that, and probably the thought was that if somebody’s lying in bed all the time and you stand them up, then maybe their depression may be cured. That is how depression was treated, and probably at that time the major medical societies would have been endorsing that kind of treatment.
But in today’s day and age, whoever I have shown that picture to, you almost gasp in horror and you say, “This looks like a scene out of a horror movie.” So that makes you think, OK, if this was just a couple of hundred years ago, what are some of the things that we are doing in medicine today that somebody two or three hundred years later will look at, and they will gasp in the same way, thinking, “Oh my God, that’s what we were doing”? But today we’re doing it; that is the best out there.
In the same way, if you take, let’s say, a woman from today who’s going through cancer treatments and she loses her hair and you see all those patchy bald spots, a few hundred years later, when chemotherapy is a thing of the past, people will look at pictures of today’s women, and they will be just terrified looking at those pictures, and they will say, “Oh my God, this is what you guys were doing at that time.” So that’s where I start.
But I also want to caution you that for anybody I have given this analogy to, the next conclusion they derive from it is that chemotherapy is bad, it’s poison, it’s sinister, it should not be done. But in today’s day and age, it is still the mainstay of treatment of many cancers, and science is progressing. If you look at science, you know, we get this question a lot, where people say, “Oh, why is there still no cure for cancer?” You just have to zoom out a little bit. If you compare cancer care, or cardiac care, or any other care, from three years ago, you may not see much of a difference. But if you look at the difference in care from 30 years ago or 50 years ago, which is not a big time frame in the history of the world or the history of medicine, you will see that we’ve made tremendous, tremendous leaps and bounds in how treatment is done.
So for people who do not practice oncology, or who are non-medical, chemotherapy consists of drugs that go through the IV, and they kill the cancer cells, but they also kill normal cells in the body, and that’s how you can have low blood counts and you can lose your hair. But now there are new treatments coming, such as immune therapy and oral molecularly targeted therapies. They are more effective than chemotherapy, but they don’t have some of those severe side effects, including the hair loss. They have not yet taken the place of chemo, but they are now getting there. And as I’ve said here before as well, as an oncologist, my dream is, I hope, that within my career, within my lifetime, before I retire, I will see a chemotherapy-free world of medical oncology. So that is really the preamble of what I wrote about.
Kevin Pho: So take us into the exam room, into one of those conversations. Whenever a patient comes to you and they’re concerned about losing their hair from chemotherapy, take us into the exam room. Tell us what that conversation is like.
Farhan S. Imran: Sure. So basically, some women are more concerned, and I say women because men are also concerned, but typically men are not as concerned about it as women are. And some women have literally even refused chemotherapy just because of the hair loss issue.
So the first thing that I do, I mean, of course you want to reassure them, but the first thing I do is ask them, “How long have you had the same hairdo?” Actually, I can put that question to anyone. I can say, “Kevin, how long have you had the same hairdo?” Or for anybody who’s watching this podcast, I ask them, “How long have you had the same beard?” Nine out of 10 people will say that they have had the same hairdo for as long as they can remember, five years, 10 years, or forever. But when you go through chemotherapy, when you lose the hair and when the hair comes back, the hair comes back with a different texture, a different color, and a different style, and it goes through different lengths. And those people who handle this issue best style their hair at every different stage in such a nice way that they carry themselves really well.
So it’s not as much our fear of losing hair, but it is a fear of how we will look in the eyes of others. An example is, if one morning I, by mistake, shave the right side of my mustache, how will I walk into work? I’d be extremely, deeply embarrassed. So the fear of embarrassment is really what is driving them.
So then I tell the patients, “You know, those people who love you will not judge you for whatever look you have. They will always love you like that. And really, there will be very few people who will look at you and you will look odd to them, and everybody will be very understanding of it. So all this is inside your own head. This is you looking at how you are looking at yourself.” So I try to tell them, “You know, think about it and try to come out of that fear.” It’s easy for me to say, but at least I’m verbalizing my support for them at such a time. And then there are so many ways. Women will wear wigs and bandanas, and some women will carry the bald look, and they will actually look really very good. And the funny thing is that sometimes the new look looks better than what their older look was. So that is one of the things that I talk about.
Another thing that I touch upon is, look at movie stars. Let’s say, look at Tom Hanks, or look at Brad Pitt, or look at Meryl Streep. In every movie, they have a different look. If you look at Tom Hanks in “Forrest Gump,” or if you look at him in, I don’t know, “Cast Away,” they come in with a different look, so much so that we get used to their different looks. So if somebody asks, “What is Tom Hanks’ main look?” there may be a look that comes to your mind, but they will look good in each one of their looks. It will not look odd to us; it will look good to us.
Some people in life are the ones who are always experimenting with their hair, with their look, with their clothes, and they are wearing different things. Most of us get into this uniform. If I wear a jacket to work, then every day I’m wearing a jacket to work. But the people who mix it up don’t have that fear as much as the people who have had the same look all along. So I just try to give that example, just to try to reach into the patient’s mind and to tell them, “You know, just think about it that way.” Maybe that will help them.
And then one other point that I wanted to make is that some women may appreciate this example and some may not. When a woman comes to me with breast cancer and she has to go through three, four, five months of chemotherapy and go through all these changes in how her hair looks and how her body looks, and then it takes another five or six months for her to come back to her prior self, sometimes I give them the example of pregnancy. For a woman, becoming pregnant is one of the most beautiful things, but it’s also one of the most difficult things. For example, Madonna, when she became pregnant, after the baby was born, a journalist asked her, “How was your pregnancy?” And she said, “I think this is the biggest joke that God played on a woman.”
Anyway, jokes aside, when you get pregnant, you can gain weight, and there are unflattering symptoms, nausea, bloating. But at the end of the day, when the baby is born, it’s all for a good cause. When you look at that baby, you’re so much in love with that baby that all the difficulties of pregnancy are considered worth it. And then it takes some effort to bring yourself back to the same weight and the same fitness, but eventually you get there.
It’s the same thing with chemotherapy. The goal is cure. The goal is the cure of that cancer, so that cancer doesn’t take the patient’s life. Fine, the body goes through these changes, but eventually, if you see women a couple of years after chemotherapy, you can’t even tell that they went through any treatment like that. Some women, that example may settle in well with them, but that’s just my attempt to reassure them that they’ll be OK.
Kevin Pho: So when you have these conversations with patients and you share that approach, what is the spectrum of responses that you get?
Farhan S. Imran: I feel that a lot of women do hear that and they do understand, but still the anxieties remain. No matter how many words you use, they remain very, very anxious. Basically, I think what helps a lot is, rather than having one conversation, having ongoing conversations approaching the same topic. Also, some of the other family members who are in the room can talk to the patient along the same lines when they are at home and address these issues, rather than not confront them and brush them under the carpet. So, repeated discussions with the patients. Our nurses are excellent. Our oncology nurses have repeated discussions with them, but the anxieties remain.
But the thing is that after chemotherapy starts, in about two to three weeks the hair starts falling out. And once the hair starts falling out and once they start getting their new look by wearing a wig or a bandana, then it settles down. Then they say, “OK, well, probably it was not as bad as it was before.” It’s the period between the diagnosis and the start of chemotherapy that is the most crucial.
Kevin Pho: And give us a sense of when the hair does grow back after chemotherapy completes.
Farhan S. Imran: So basically, what I tell my patients is that it takes as long as it takes for the chemotherapy regimen to complete. Some chemotherapy regimens may go on for three months versus six months. Some women may think that the hair will come back right away, in a couple of weeks after the chemotherapy is finished. No, it will be a very slow process, and it may take as much time. For example, if it’s a six-month chemo process, it may take another six months for the hair to get to a point where it looks like maybe they have not lost their hair. So it does take several months, but it does happen. It is very, very rare that a woman may have long-term hair loss, but that is very rare. Most of the time, the hair grows back.
There are some strategies, like cold scalp cap therapy, which is not done universally. Some centers do it and some patients choose to do it, but that in itself can be a cumbersome and an expensive process, and it’s not 100 percent that if you do it, you will definitely not lose any hair. It makes a small difference, but what makes the most difference is how the woman carries herself through each stage of hair loss and hair regrowth. That’s what matters the most.
Kevin Pho: We’re talking to Farhan Imran. He’s a regular contributor to KevinMD and a regular guest on the podcast. His latest article is “To my patient who is going to lose her hair from chemotherapy.” Farhan, what are some of your take-home messages that you want to leave with the KevinMD audience?
Farhan S. Imran: My take-home message on this one, Kevin, would be that anybody who has been diagnosed with cancer and is now going to go through any treatments, chemotherapy or radiation, needs a lot of support, and anybody who is in their life should reach out to them and give support. I cannot emphasize the importance of pep talks in oncology, or in end of life, or in any kind of care.
So let’s suppose I work at my workplace, and I know someone relatively peripherally. I don’t know them as well, and I find out that they’re diagnosed with cancer or any other major negative event in life. Our common reaction usually is that we’ll give them their space. We’ll just say hi, and we just say, “OK, I’m sorry,” and then after that we just try to stay away. But my message to people is: Please reach out. Please reach out. There’s absolutely nobody who is going to mind. You can carefully ask them, “Hey, can I reach out?”
And by reach out, I mean, let’s say somebody is in housekeeping, and all of a sudden they have lost their job because they’re dealing with cancer or any other thing. Now they’re sitting at home, and all day they’re doing nothing. Their family members and their friends are also at work, and if you think that they’re going to be there, they’re OK. I mean, we should just reach out, take out time in the evening or on the weekend. Just a phone call, or go in and just sit there and talk to them. That is the main, biggest treatment of these conditions.
Like I’ve said before, the science of medicine has progressed a lot, which is amazing, but the art of medicine is being lost in the EMRs and in the telehealth visits and all that. So this is really what the patient needs. The patient needs people, and those people are nobody else. Those are us. So that’s the message that I would give to anyone: Just look around you and reach out to anybody who’s going through a hard time.
Kevin Pho: Farhan, thank you so much for coming back on the show and sharing your time and insight.
Farhan S. Imran: Thank you, Kevin, and thanks for giving a voice to all the health care providers of America and across the world.
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