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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 90-96

Body image disturbances among breast cancer survivors: A narrative review of prevalence and correlates

1 Amity Institute of Psychology and Allied and Sciences, AIPS, Lucknow, Uttar Pradesh, India
2 Department of Endocrine Surgery, KGMU, Lucknow, Uttar Pradesh, India
3 Department of Psychiatry, KGMU, Lucknow, Uttar Pradesh, India

Date of Submission23-Jul-2021
Date of Decision09-Dec-2021
Date of Acceptance18-Dec-2021
Date of Web Publication31-Mar-2022

Correspondence Address:
Monika Thakur
AIPS, Amity University Noida, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_170_21

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Body image is an essential aspect of femininity. Body image disturbances occurring due to breast cancer pose a difficult challenge, which can impact the quality of life of breast cancer survivors. Various treatment modalities used to cure cancer may result in major alterations of body image. The purpose of this review is to describe the magnitude of body image disturbances and the associated factors which influence the quality of life. A thorough literature search was performed to identify articles related to body image disturbances in patients with breast cancer. Google Scholar, PubMed, Scopus, and Web of Science databases were searched using key terms such as “body image disturbances,” “sexuality,” “women,” and “breast cancer.” Original research articles, systematic reviews, and meta-analyses published in English from 2000 to 2020 that reported on body image as the main variable using standardized tools and had a sample size of at least 100 were considered eligible for inclusion in the review. A total of 40 articles matched the inclusion criteria, out of 100 that were identified from the database search. Our review suggests that in patients with breast cancer, the type of treatment, primarily modified radical mastectomy, and age have a significant association with disturbed body image, resulting in physical or psychological distress, eventually leading to difficulty in partnered relationships and sexual intimacy. Body image disturbance is an indispensable part of female health, and due care must be taken along with treatment to avoid psychological and physical distress.

Keywords: Body image disturbances, breast cancer, sexuality, women

How to cite this article:
Thakur M, Sharma R, Mishra AK, Gupta B. Body image disturbances among breast cancer survivors: A narrative review of prevalence and correlates. Cancer Res Stat Treat 2022;5:90-6

How to cite this URL:
Thakur M, Sharma R, Mishra AK, Gupta B. Body image disturbances among breast cancer survivors: A narrative review of prevalence and correlates. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 28];5:90-6. Available from: https://www.crstonline.com/text.asp?2022/5/1/90/341248

  Introduction Top

Breast cancer is the major cause of the increasing death rate among women.[1],[2] The prevalence of breast cancer has been increasing.[3] Treatment of breast cancer involves various external and internal bodily alterations. Moreover, the psychological and physical changes that occur due to the disease and its treatment affect sexuality and the body image of women.[4] Changes in bodily appearance can result in low self-esteem and poor self-concept among women, leading to stress, anxiety, and other related disorders that impact the overall quality of life.[5],[6]

Body image is an important aspect of the sexual health of individuals. Body image has been defined in three constructs among breast cancer survivors: affective feelings (feeling feminine and attractive), behavioral changes (avoiding people because of one's appearance), and cognitive changes (satisfaction with appearance or with scar).[7] Body image can also be defined by thoughts, feelings, and perceptions about the body and its functions.[8]

Changes in body image in patients with breast cancer can occur due to chemotherapy, radiotherapy, and surgery. Chemotherapy can cause reversible hair loss, radiotherapy can damage the body tissues, and surgery may lead to more immediate effects with partial or complete removal of the breast.[9],[10]

Changes in the physical appearance can make women uneasy and lead to body image disturbances. Studies have reported the prevalence of body image disturbances to range from 31% to 67% .[2],[11],[12] Body image disturbance can lead to psychological distress and is associated with depression and anxiety.[13],[14],[15] Currently, there are no criteria for diagnosing body image disturbances, which is a different entity than body dysmorphic disorder (BDD). BDD is defined as a preoccupation with an “imagined” defect in one's appearance, which is a psychiatric disorder.[16] Therefore, it becomes difficult to clinically identify and address body image disturbances among patients with breast cancer. This narrative review aims to describe the existing knowledge about body image disturbances and to explore the factors associated with it [Table 1].
Table 1: Prevalence of body image disturbances and associated factors

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  Methods Top

A thorough literature search was performed to identify articles related to body image disturbances in patients with breast cancer. Google Scholar, PubMed, Scopus, and Web of Science databases were searched using key terms such as “body image disturbances,” “sexuality,” “women,” and “breast cancer.” Original research articles, systematic reviews, and meta-analyses published in the English language from 2000 to 2020 (and a few landmark research articles published outside this date range as well) that reported on body image as the main variable using standardized tools and had a sample size of more than 100 were considered eligible for inclusion in the review. Studies with a bias and those in which body image was not the main aspect of the study were excluded. Additionally, non-research literature, conference meeting abstracts, and letters to the editor were excluded.

We identified a total of 100 articles, of which 40 fulfilled the eligibility criteria. The majority of the studies used a cross-sectional design and used the Body Imaging Scale as an assessment tool. [Figure 1] shows the flowchart for the selection process of the studies included in this review.
Figure 1: Flowchart for selection of studies for the review on body image disturbances in breast cancer survivors

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Body image disturbances and sexuality

The breasts have a social significance associated with motherhood, femininity, and sexuality.[28],[29] They are considered to be fundamental and deep pervasive aspects of one's overall personality.[30] Breast cancer affects a woman's body image and sexuality. Sexuality and intimacy are as important to people suffering from breast cancer as they are to healthy adult women. However distinct, the concept of body image and sexuality interchangeably influence the quality of life of breast cancer survivors.[12] It has also been found to impact intimacy and partnered relationships.[25],[31]

Sexual difficulties, in terms of physical functioning, are associated with negative body image perceptions.[32] Sexual interest may be disturbed due to changes in hormone levels or decreased sensation in the affected part of the breasts. Changes in hormone levels may lead to hot flashes, vaginal dryness, atrophic vaginitis, decreased libido, and premature menopause, which can all negatively affect sexuality.[33] Patients with breast cancer also report concerns about physical appearance, hair loss, and decreased libido.[34] Women with breast cancer and body image disturbances are 2.5 times more likely to experience issues related to sexual functioning, which underlines the vitality of addressing both these topics concurrently.[35] Difficulties in partnered relationships are majorly reported by young women.[36] In a qualitative exploration of body image disturbances among breast cancer survivors aged 50 years and younger, participants expressed issues of body disfigurement and inability to feel desirable by their partners as a result of breast surgery.[37] Another study among breast cancer survivors found that the sexual role and performance were significantly affected in women who had undergone a mastectomy as compared to those who received a lumpectomy.[25]

Body image disturbances and age

In general, cancer is considered to be a disease of aging. Breast cancer, in particular, occurs commonly among women in the fifth decade of their lives.[38] Research studies highlight that distress and body image disturbances are commonly observed among young adult women, suggesting a significant association of body image disturbances with age.[24],[35],[37] A study on breast cancer survivors aged between 25 and 50 years showed a significant association between body image disturbances and emotional well-being, breast cancer-specific concerns, and health-related quality of life.[3] Kenny et al. reported similar findings, showing poorer emotional status, social functioning, and global health status among younger women.[39] A qualitative research study reported that women want age-specific interventions for their body image issues.[40] The majority of the studies have reported the association of younger age with body image disturbances. A literature review conducted by Figueiredo et al. and Davis et al.[41],[42] suggested that body image disturbances are important among older breast cancer survivors as well and various factors such as age, menopause, mental health, type of treatment, and exercise are responsible for body image disturbances. However, few other studies have suggested no association between body image and age.[17],[20],[43]

Body image disturbances and treatment

The breast cancer survival rate is increasing due to the advent of newer treatment modalities.[1] Receiving multimodality treatment often results in sudden and troubling changes in the physical appearance of a person. Our review of the literature suggests that various treatment modalities, such as surgery, radiation therapy, and chemotherapy, can have varying impacts on body image disturbances. Women who underwent reconstructive surgeries were found to have better body image[12],[26] compared to those who underwent a modified radical mastectomy. These findings are supported by Prates et al.'s study[18] which reported that mastectomies had a negative impact on women's body image. Several other studies have explored how radical surgeries like a mastectomy can change how women feel about themselves, their social interactions, and their willingness to engage in physical intimacy.[15],[18],[20] Studies have also reported reported that chemotherapy and radiation therapy are also associated with body image disturbances.[39],[44] Women receiving chemotherapy reported poor body image and were anxious regarding hair loss and other possible side effects compared to those with cancer who did not receive chemotherapy.[24],[43] However, Gupta et al., in their study, found no meaningful relationship between clinical variables such as the type of treatment or duration of illness and body image disturbances among breast cancer survivors.[43]

Body image disturbances and psychological concerns

Individuals tend to experience some level of distress, fear, and worry when diagnosed with cancer. Physical symptoms of breast cancer are more likely to induce emotional distress.[45] Studies among breast cancer survivors reflect a significant association of body image disturbances with emotional well-being.[12] Perception of a negative image about oneself tends to lower the self-esteem of an individual, which makes them more vulnerable to the development of mental health issues.

Psychological and physical symptoms, such as depression, anxiety, fatigue, and fear of recurrence, were found to be associated with body image disturbances.[15],[46] Several studies have shown that body image disturbance was associated with increased psychological distress in breast cancer survivors, which is consistent with findings from other non-breast cancer studies. This highlights the importance of body image in overall psychological well-being.[24],[47],[48],[49],[50] The most common disorders associated with body image disturbances are anxiety and depression. Anxiety was found to be commonly associated with the alteration of physical appearance.[51],[52] A positive correlation between body image disturbances has been observed with depression and stress.[11]

Body image disturbances and coping strategies

Different individuals cope with the traumatic experiences of breast cancer differently. Studies have reported that religious beliefs, emotional social support, and realistic acceptance are important coping mechanisms among women with breast cancer.[52],[53],[54] Women try to accept their altered appearance through various coping strategies. Clinical factors (stage of cancer, and adjuvant therapy) play an important role in determining the patient's perception of body image and coping strategies.[55] The uncertain course of the journey of cancer and the fear of recurrence may increase emotion-focused coping, leading to less flexible coping strategies and, consequently, more severe anxiety and distress.[56] Cognitive and behavioral strategies are used to cope with the perceived threat to body image and stress.[57] Women cope well with cancer if they have a better conceptualization of their body image.[58] According to a study conducted by Yamani Ardakani et al.,[59] positive coping strategies like “positive rational acceptance” were found to be associated with better body image; the least commonly used strategy was “avoidance.” Denial was reported to be a potentially used maladaptive coping strategy among patients with breast cancer.[43] Helplessness was another commonly used strategy that was negatively associated with well-being.[60] Further, studies suggest that culture-specific influences impact the way people see their health and disease and may affect their way of coping with it.[61]

Body image disturbances and psychological interventions

Very few studies have reported on the interventions related to body image disturbances. The results of these studies have not been replicated, and the accuracy of the tools used in these studies has not yet been established. Cognitive-behavioral therapy is the most commonly used intervention [Table 2].
Table 2: Psychological interventions related to body image disturbances

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  Discussion Top

Body image disturbance is a significant issue among breast cancer survivors. Previous studies among women with breast cancer who experienced some degree of concern reported the prevalence of body image disturbances to range between 15% and 33%.[2],[12] Our review demonstrates that body image disturbances are often associated with various other factors such as psychological and physical issues, sexuality, and interpersonal concerns that may affect partnered relationships of survivors.[24],[31],[45],[46],[70] Many studies have shown an association of various factors such as radical mastectomy, young age, premenopausal status, and hormone-associated changes with body image disturbances.[33],[34]

Our review points out that currently there are ample cross-sectional studies on body image disturbances. However, retrospective, prospective, and longitudinal studies in this area are few, which limits the interpretation of the available evidence, providing only a very narrow view of this survivorship issue.[71]

Additionally, interventional studies to observe the effect of psychological interventions to reduce psychological distress and improve the quality of life among breast cancer survivors would be the next logical step in the progression of research work in this area.

Many individuals are embarrassed or ashamed to voluntarily mention their body image concerns.[2] Therefore, a regular proactive assessment using tools that are specifically tailored for body image concerns needs to be carried out. Finally, variations in sample size, limited diversity of the participants, and the variety of tools used (the most commonly used tool was Body Imaging Scale [BIS]) in the studies further limit the confidence with which we can generalize these results to all patients with breast cancer.

This literature review has potential limitations. We may have missed relevant studies by the period, the limited number of databases searched, and fewer keywords used for the database search. Moreover, studies in which body image was considered under a more general construct and coping strategies and studies where body image was a subcomponent of the study were not included. These deficiencies can be made up by conducting studies with other designs and considering other factors for research beyond treatment, sexuality, such as patient satisfaction or quality of life.

  Conclusion Top

Learning to be comfortable with one's body during and after breast cancer treatment is a personal journey, one that is different for every woman. Body image disturbance is an important concern among women with breast cancer that needs to be addressed regularly throughout the cancer continuum. Body image issues may not be the most pressing concern at the beginning of the cancer journey, but in the long run, they may have a dramatic effect on the survivor's quality of life. Failure to address these issues may create a significant void in a woman's femininity.

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Conflicts of interest

There are no conflicts of interest.

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