Predictors of Breast Cancer Risk among Hair Dye Users at El-Manial University Hospital

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54
1* 1 2
Salwa Hagag Abdelaziz , Hala Ebrahim Abodef , Amel Dawod Goudia
ABSTRACT
Breast cancer is the most common cause of cancer related deaths among women worldwide. Concern has
been highlighted by many authors that mutagenic substances and carcinogens were found in hair dye
products. So the use of hair dyes may increase the risk of breast cancer. Therefore, the aim of the current
study is to determine whether the use of hair dyes is associated with the risk of breast cancer. A descriptive
correlational design was adopted in this study and a structured questionnaire was developed by the
researchers to collect the data related to patients' characteristics, such as; age, level of education, health
status and nature of hair dyes. Data was obtained from 250 patients at El- Manial University Hospital,
Cairo University. The study findings revealed that (64.1%) of patients age ranged between 26- 36 years
with Mean ± SD (36.8560 ± 8.24836). After adjusting the confounding variables such as age, family history
and level of education, the study showed a positive association between using hair dyes and breast cancer.
The risk of breast cancer increased with using semi-permanent as compared to permanent type (OR: 1.480,
95% CI 0.896 - 2.443). The risk increased with using a dark color of hair dyes (OR: 1.312, 95% CI 0.708 -
2.429). Therefore, Patients should be instructed to use natural substances such as henna and other
suggested alternatives to color hair, instead of using chemical substances.
THE MALAYSIAN JOURNAL OF NURSING | VOL. 9 (3) January 2018 |
1Lecturer of Medical Surgical Nursing, Faculty of nursing, Cairo University, Egypt
2Lecturer of Maternity and New Born Health Nursing, Faculty of nursing, Cairo University, Egypt
*Corresponding Author’s Email: nadakimo2005@yahoo.com
INTRODUCTION
The use of hair dyes can be dated back around
4000 years. In this respect, researchers analyzed the
hair of Ramses II in Egypt and discovered that the use
of henna to color the hair was common among the
Pharaohs (Klimczak, 2016). Also using vinegar to
darken graying hair was found in combs in the days of
th
Roman Empire. In the end of 19 century, Oxidative
hair dyes were introduced for coloring human hair. In
the 1970 and 1980's, many types of hair dyes were
introduced to the public (International Agency for
Research on Cancer, 2010).
Hair dyes are divided into three types according to
their color fastness. The first two types are temporary
and semi-permanent hair dyes and are non-oxidative
(non-permanent), do not penetrate into the hair shaft and
lasts for 5 to 10 shampoos. The third type is permanent;
oxidative hair dyes and are most commonly used
worldwide (National Cancer Institute, 2017). Also, this
type contains colorless substances such as aromatic
amines (intermediates) and phenol. Whenever, adding
hydrogen peroxide to the previous substances, chemical
reactions happened to form the dye and cause chemical
changes that lead to damage in the hair shaft and change
its color until the hair is replaced by new growth. In
addition, several studies reported that aromatic amines
are strongly mutagenic and elevated levels of DNA-
adducts of these amines have been detected from breast
ductal epithelial cells of hair dye users (Turesky et al.,
2003; Baan et al., 2008; Heikkinen et al., 2015).
In relation to the color of hair dyes, Clausen et al.,
(2006) were carried out study and showed that the use
of dark-colored dyes (black, dark-brown) needs a
higher concentration of intermediates and oxidative
agents which accentuated the damage to the hair. A
recent study conducted by (Llanos et al., 2107) reported
that the use of dark hair dye was associated with
increase breast cancer risk. Other study conducted by
PREDICTORS OF BREAST CANCER RISK AMONG HAIR
DYE USERS AT EL-MANIAL UNIVERSITY HOSPITAL,
CAIRO UNIVERSITY, EGYPT

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PREDICTORS OF BREAST CANCER RISK AMONG HAIR DYE USERS
| VOL. 9 (3) January 2018 | THE MALAYSIAN JOURNAL OF NURSING
(Zhenga et al., 2002) reported no significant
association between breast cancer and other factors
related to using hair dyes such as age at first use,
duration of use and a total number of applications. The
European Commission (2014) highlighted that 60% of
women and 5–10% of men in Europe use hair dyes on
an average of six to eight times per year. The use of hair
dyes and its possible risk of breast cancer have been
investigated in many countries from time to time;
however, still the associations between the concerned
variables yielding equivocal findings.
The association between using hair dyes and breast
cancer has been explored in many meta-analysis
studies such as study conducted by (Takkouche, et.al,
2005) reported no significant association between
female breast cancer and any hair dye users. Other
study conducted by (Green et al., 1987; Zheng et al.,
2002; Bolt & Golka, 2007; Mendelsohn et al., 2009)
found no association between hair dye use and breast
cancer risk. In contrary to those studies, a study carried
out by (Ambrosone et.al, 2007) highlighted the positive
association between the presence of carcinogenic
adducts and using light colored hair dye. Another study
conducted in USA by (Cook et.al, 1999) reported that
among women who used hair coloring products, there
was an association with a 30% borderline significantly
increased risk of breast cancer as ever use of any hair
coloring products was associated with a twofold
increased risk and three fold among those who had a
total number application of more than 90 episodes.
However, still the results are inconclusive about the
association between breast cancer and using hair dyes.
Considering the risk factors of breast cancer such
as age, analysis by (Nasca et al., 1980) revealed a
significant association between hair dye use and breast
cancer among women 40–49 years of age. Also Shore et
al., (1979) found a positive association between hair dye
use and breast cancer was greatest among women over
50 years of age and. Regarding the family history,
(Nasca et al.,1980) highlighted a statistically significant
association between women with a history of benign
breast cancer and use of hair dyes. In-addition, Saitta et
al., (2013) found that patients with a first-degree family
history of cancer should be cautious in using hair dye
because there may be a cumulative risk.
It has been observed in breast cancer cases
admitted to El Manial University Hospital that most of
the women were using hair dyes. In Egypt, few studies
were conducted to determine whether the use of hair
dyes is associated with the risk of breast cancer. Nurses
working at surgical units have repeated frequent contact
with breast cancer patients. So, in collaboration with the
multidisciplinary team, nurses are in a strategic position
to assess the association between breast cancer and
chemical exposure such as hair dyes and help patients to
develop strategies to manage its effects. This could be
achieved through providing adequate information on
breast cancer risk and how to use hair dyes safely and
other alternatives. Therefore, the aim of the current
study is to determine whether the use of hair dyes is
associated with the risk of breast cancer.
The researchers carried out this study to alert the
nursing professionals working in surgical units to
educate patients to use natural substances such as
henna. This research could provide health care
providers with an in depth understanding related to this
risk of breast cancer and how to minimize chemical
exposure that could be reflected positively on patients
care, decrease incidence of breast cancer and economic
issues. It can be assumed that the findings of this study
might establish evidence based data that can promote
nursing practice and research as well. Moreover, this
effort will generate attention and motivation for further
nursing researches in this area.
Research hypothesis
H: Use of hair dyes may lead to breast cancer.
Subject and Methods
Research Design:
A descriptive correlation design was utilized to
conduct the current study. The purpose of this design
gives an indication of how use of hair dyes may predict
breast cancer in the form of correlation without
establishing causation of the research findings (Wood &
Habber, 2015).
Setting:
The institution from which patients were recruited
was breast surgery unit at El-Manial University
Hospital, Cairo University. This unit aims to provide
care for breast surgery patients to meet the highest
international standards.

56
PREDICTORS OF BREAST CANCER RISK AMONG HAIR DYE USERS
THE MALAYSIAN JOURNAL OF NURSING | VOL. 9 (3) January 2018 |
Sample:
A convenience sample consisting of 250 patients
with breast cancer, representing patients accepted to
participate in the current study. The inclusion criteria
are age above 26 years, only female with breast cancer
and the exclusion criteria includes patients using hair
dyes less than 5 times and patients with impaired
memory or cognitive functions were also excluded.
Data collection:
Face-to-face interview was done to collect socio-
demographic data covering items related to age, level of
education, occupation, marital status, residence and
income. Also health assessment questionnaires were
developed by the researchers and elicited information
related to family history of and diagnosis of breast
cancer either benign or malignant. In-addition, modified
questionnaire of National Cancer Institute based on
research conducted on hair dyes use and risk of cancer
(Zheng et al., 2002). It suggests that women generally
are able to estimate the number of hair dyes application
during life, age at first use, color of dyes (dark or light)
as well as types of hair dyes used. Age at first dye used
was categorized as: Under 25 years, 26-40years and 40
years or older. The different dye types were classified as:
'Semi-permanent' a color that removed after several
washes, 'Permanent' a color that does not removed by
wash and still until the hair replaced by new growth. The
color of hair is categorized as light (blond, brown) and
dark (brown, black).The number of application of hair
dyes is divided into 2 categories as: less than 20 and
more than 20 times in life.
Validity & Reliability of the tools
To ensure objectivity and clarity of the study tool a
pilot study was conducted on 10% of the patients and
necessary modifications were done. Content validity of
the designed tool was reviewed by a panel of five
experts in the field of medical surgical nursing, surgery
and pharmacology.
Ethical Consideration
A written permission was obtained from the head of
the department of surgery. Individual participation in the
study was voluntary. The benefits and the purpose of the
study were explained for each patient. Also informed
consent was reviewed with all patients prior to the
interview and signed accordingly. Confidentiality was
assured by keeping privacy of patients' information.
Data Analysis
Collected data was analyzed using statistical package
for the social science (SPSS) program, version 24. A
descriptive statistics such as frequency, percentage,
mean, standard deviation and range were utilized.
Inferential statistics such as logistic regression analysis
was carried out to estimate the association between
breast cancer and using hair dyes and to eliminate the
effect of confounding variables such as age, level of
education, and family history of breast cancer. After
adjusting the confounding variables, Odds ratios (OR)
with 95% confidence intervals (CI) were reported.
Also the (P-value) was calculated accordingly.
RESULTS
Table1: Frequency and percentage distribution of the
patients' characteristics ( N=250)
Variables
Age
of
participant
:
26-36
37-47
48-58
More
than 58
Mean±SD
36.8560
± 8.24836
Marital
status
Single
Married
Divorced
Level
of
education
Cannot
read or
write
Primary-preparatory
Secondary and above
Income
Adequate
Inadequate
Occupation
Employed
Unemployed
Place of residence
Cairo
Outside Cairo
No
161
88
1
0
148
52
50
14
113
123
141
109
136
114
102
148
%
64.4
35.2
0.4
0
59.2
20.8
20
5.6
45.2
49.2
56.4
43.6
54.4
45.6
40.8
59.2
Table 1 showed the higher percentage (64.1%) of
patients age ranged between 26 - 36 years with Mean ±
SD (36.8560 ± 8.24836) and around half of them (45%)
their level of education was primary and secondary
while (59%) of them were living outside Cairo.

PREDICTORS OF BREAST CANCER RISK AMONG HAIR DYE USERS
57 | VOL. 9 (3) January 2018 | THE MALAYSIAN JOURNAL OF NURSING
Table 2: Frequency and percentage distribution of
the patients' health status (No=250)
Variables No %
Familyhistory
Yes
No
150
100
60
40
Diagnosis
Benign
Malignant
136
114
54.4
45.6
Table 2 illustrated that the highest percentage
(60%) of patients having family history of breast
cancer. Also the above table showed that (54.4%) and
(45.6%) of patients were diagnosed as benign and
malignant breast cancer respectively.
Table 3: Association between characteristics of hair
dyes use and breast cancer risk
OR: Odds ratios; CI: confidence interval; * Significant at P < 0.05
Table 3 revealed positive association between
types of hair dye and diagnosis of breast cancer as
increase risk was apparent in semi-permanent as
compared with permanent users (OR: 1.480, 95% CI
0.896 - 2.443).Also excess risks of breast cancer were
apparent in with patients using hair dyes more than 9
years (OR : 1.824,95%CI 1.094 - 3.040 ). Also color of
hair dyes and number of application were positively
associated with breast cancer (OR : 1.448,CI 95%
0.781- 2.684).Also patients using hair dyes more than
20 times developed a higher risk of breast cancer than
those who use it less than 20 times(OR:1.809, 95%CI
1.069-3.060) and P value (0.021) .
Table 4: Association of hair dyes use and breast cancer
risk
OR: Odds ratios; CI: confidence interval; * Significant at P < 0.05
Table 4 showed that the risk increased with using
dark color of hair dyes with those used permanent and
semi-permanent hair dyes (OR: 1.312, 95% CI 0.708 -
2.429). Also the same table revealed no excess risks
were observed with number of application and age at
first use (OR: 0.478, 95%CI 0.282-0.812 and OR: 0.996,
95% CI 0.967-1.026) respectively.
Table 5: Association of hair dyes use and breast cancer
risk
OR: Odds ratios; CI: confidence interval; * Significant at P < 0.05
Table 5 revealed that no excess risks of breast
cancer were observed with years of using hair dyes,
number of application and age at first use.
Variables
Benign
NO
=
136
Malignant
NO
=
114
OR
95% CI
P
Value Lower Upper
Type of
Hair
dyes
Permanent 80 (58.8%)
56
(49.1%)
Semi
permanent
56 (41.2%)
58 (50.9%)
0.125 1.480 0.896 2.443
Years of
using hair
dyes

<

9
years
90
(66.2%)
59
(51.8%)

≥

9
years
46
(33.8%)
55
(48.2%)
0.021*1.824 1.094 3.040
Color of
dyes
Light (blonde,
light brown)
(82.4%)
112 87 (76.3%)
Dark (brown,
black) 24 (17.6%) 27 (23.7%) 0.238 1.448 0.781 2.684
Number
of
Application
(During
life)
<20 97 (71.3%) 66 (57.9%)
≥20 39 (28.7%) 48 (42.1%) 0.026*1.809 1.069 3.060
Age at1st
Use Mean±SD 32.60± 8.51 31.48 ± 8.50
Range 21 – 45 21 – 54 0.304 0.985 0.956 1.014
Permanent
Semi
permanent P-value OR 95% CI
NO = 136 NO = 114 Lower Upper
Ye2ars of
using hair
dyes
<9 years 110 (80.9%) 39 (34.2%) 0.000
≥9 years 26 (19.1%) 75 (65.8%) 0.123 0.069 0.219
Color of
dyes
Light (blonde,
light brown)
111
(81.6%)
88
(77.2%)
0.387
Dark (brown,
black)
25
(18.4%)
26
(22.8%)
1.312 0.708 2.429
Number
of
Application
(During
life)

<
20
99
(72.8%)
64
(56.1%)
0.006
≥
20
37
(27.2%)
50
(43.9%)
0.478 0.282 0.812
Age
at
1st
Use
Mean
±
SD
31.96
±
8.30
32.24
±
8.78
0.801
Range
22
–
54
21
–
44
0.996 0.967 1.026
Variables Dark Light P-value OR 95% CI
NO = 51 NO = 199 Lower Upper
Years of
using hair
dyes
< 9 years 37 (72.5%) 112 (56.3%) 0.035
≥ 9 years 14 (27.5%) 87 (43.7%) 0.487 0.248 0.957
Number of
Application
(During
life)
<
20
38
(74.5%)
125
(62.8%) 0.118
≥
20
13
(25.5%)
74
(37.2%) 0.578 0.289 1.155
Age
at
1st
Use
Mean
±
SD
28.65
±
8.06
32.97
±
8.41 0.001
Range
21
–
54)
22
–
45
0.937 0.899 0.975

PREDICTORS OF BREAST CANCER RISK AMONG HAIR DYE USERS
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THE MALAYSIAN JOURNAL OF NURSING | VOL. 9 (3) January 2018 |
DISCUSSION
Over the past several years, concern has been raised
in a number of studies that the potential risks associated
with using hair dyes and development of breast cancer.
In 2013, statistical figures in Egypt showed that breast
represents 37% of all females' cancer Ismail, Abdel-
Hamid & Abdel-Naby, 2013. This could be due to lack
of patient's awareness regarding the risk factors of breast
cancer such as chemical exposure and in this study the
researchers are concerned with breast cancer patients
who were using hair dyes. In Egypt, few researches were
conducted to evaluate the association between using
hair dyes and breast cancer risk .Therefore, it was
important to carry out the current study. The findings of
the current study showed that overall association was
found between using hair dyes and breast cancer risk.
This findings supported by (Cook et al., 1999;
Ambrosome et al., 2007 & Heikkinen et al., 2015) as
they mentioned in their study that the use of hair dyes is
associated with breast cancer incidence. The impact on
public health may be substantial due to vast popularity
of hair coloring in modern societies In-contrary a meta-
analysis study conducted by (Tkkouche et al., 2005)
reported a contradicting result with the present study as
the researchers concluded that the reviewed data from
14 studies on female breast cancer and hair dye use
published between 1977 and 2002 found that hair dye
users had no increase the risk of breast cancer compared
with nonusers. Research on hair dye use and the risks of
other cancers is more limited. Although some studies
have shown associations between hair dye use and the
risk of developing or dying from specific cancers, these
associations had not been observed in other studies.
Because of differences in the study design, it has not
been possible to pool the findings of most cancer types
in order to increase the power to detect associations with
hair dye use. In addition, Zheng et al., (2002) &
Mendelsohn et al., (2009) concluded no strong evidence
of an association between hair dye use and risk of breast
cancer. Moreover the association between hair dye and
breast cancer was explored in the meta-analysis by
(Saitta et al., 2013) data pooled from 12 case-controlled
studies and two cohort studies did not reveal a
significant association between female breast cancer
and any hair-dye users.
Regarding to the types of hair dyes, the present
study found that increase risk was apparent in patients
using semi-permanent hair dyes. This findings is
consistent with (Zheng et al., 2002) concluded that
odds ratios were increased among patients using semi-
permanent hair dyes. While Heikkinen et al., (2015)
indicated that increase risk of breast cancer among
women using different types of hair dyes such as
temporary, semi-permanent and permanent as
compared to non users. This finding is incongruent with
other studies conducted by Green et al., 1987;
Tkkouche et al., 2005; Mendelsohn, 2009 and stated no
association between using different types of hair dyes
and breast cancer risks. Most interestingly, temporary
and semi-permanent dyes seemed to have greatest
impact in the risk of breast cancer. It has been also
depicted that permanent hair dyes containing higher
concentrations of intermediates and oxidative agents
have previously been thought to possess the most
potentially hazardous effects. Nevertheless, many of
the mode rn semi -per mane nt dyes con tain a
peroxidizing agent and may thus be considered to act as
permanent dyes with lower concentrations of oxidative
agent. Also, semi-permanent colors may contain
potentially carcinogenic substances, as many of them
contain colorless substances that after cleavage may
lead to the release of aromatic amines. In the present
study, we excluded the temporary hair dyes from the
data analysis because no patients reported using it.
In examining the variable related to the color either
dark or light dyes, the current study estimates that using
dark dye (dark brown, black) was associated with
increased risk of breast cancer. This is similar to other
study that was carried out on African American and
White women and highlighted that the use of darker
shades (dark brown and black) was associated with
increased risk of breast cancer among women (Llanos et
al., 2017). In this regards, Bolt & Golka, (2007) cited
that long-term use of dark color has been associated with
increased cancer risk in a few studies. However, these
studies have had limited power due to the low
prevalence of long-term exposure to dark color of hair
dyes.
As regards the duration of using hair dyes, the
present study found no association between years of
using hair dyes and risk of cancer. This findings is

PREDICTORS OF BREAST CANCER RISK AMONG HAIR DYE USERS
59 | VOL. 9 (3) January 2018 | THE MALAYSIAN JOURNAL OF NURSING
supported by (Zheng et al., 2002) who concluded no
association between using hair dyes and increased risk
of breast cancer. Moreover, Saitta et al., (2013) added
that with more than 200 lifetime exposures to hair dye
was not associated with an increased risk of breast
cancer.
Also the study conducted by (Wynder &
Goodman, 1983; Bolt & Golka, 2007) found no
association between using hair dye and increased risk
of cancer. Based on the vast majority of studies toward
the cancer risk of hair dye product, consumers can feel
more confident of the safety of today's hair dye
formulations. While the New York Post (2017) cited
that Professor Kefah Mokbel, a breast cancer surgeon
at the Princess Grace Hospital in London, reviewed
studies on whether there is a link between hair dyes and
breast cancer and found a fourteen percent increase in
the disease among women who color their hair.
Since the safety of hair products has been debated
for years many people regularly dye their hair, either
through a professional hairdresser or at home, concerns
have been raised regarding potential side effects from
the chemical substances present in the product hair dyes,
accordingly, the International Agency for Research on
Cancer 2010 cited that hair coloring include the use of
chemicals capable of removing, replacing, and/or
covering up pigments naturally found inside the hair
shaft, also use of these chemicals can result in a range of
adverse effects, including temporary skin irritation and
allergy, hair damage, skin discoloration and unexpected
hair color results. In addition, in vitro and in vivo studies
(in exposed human populations) have shown that some
hair dyes and many chemicals used in the hair dyeing
process can be considered mutagenic and carcinogenic.
So, it is suggested by the researchers of the current
study to use natural substances to color the hair instead
of using product that contains chemical substances
which cause complications and hazards to the skin. A
variety of natural hair coloring can be simply made at
home and alternative herbs can be used such as henna. In
addition, the patients instructed to promote a certain
color through using black tea leaves and hibiscus
flowers as a natural method to color the hair.
Furthermore, the pomegranate peel mixed with black
tea can be used as a hair spray to promote the original
hair color with no need to change it.
CONCLUSION AND RECOMMENDATION
Overall the findings of this study found a positive
association between using hair dyes and breast cancer
risk. With increasing the use of hair dyes day by day
among male and female worldwide, so spreading
awareness is necessary towards the potential effects of
exposures to chemical ingredients and natural
alternatives of hair dyes that can be used safely by any
individual. Studying something like hair dyes can be
even more complex because not all hair dyes are the
similar and thousands of different chemicals substances
are included. On top of this, the ingredients in hair dyes
have changed over the years.
· To support the study findings, the current study
needs to be replicated with large sample size in different
settings.
· Pregnant women should be advised by nurses to
avoid using hair dyes during pregnancy
· A multidisciplinary team in collaboration with Food
and Drug Administration should develop guidelines
and to be followed if any cosmetics are found to be
harmful especially in developing countries.
· Certain precaution and warning signs inside the hair
dye package should be explained to all users such as
protecting skin by wearing gloves and shampoo scalp
skin thoroughly with water.
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