Body Image and Quality of Life in Female Patients with Breast Cancer and Healthy Women

Introduction

Cancer is considered as one of the most important medical issues in today’s world. Breast cancer is the most common cancer among women, worldwide and is the second most fatal cancer, accompanied by emotional and psychological consequences (1). 

According to a report by World Health Organization, more than 1.2 million people are annually diagnosed with breast cancer (2). According to the reports by the U.S. National Cancer Institute, one out of every eight women will develop breast cancer during their lifetime (3). Given that breast cancer affects women at the age of peak efficiency, attention to this condition is of particular importance in medical circles.

Apart from physical changes, cancer also influences women’s quality of life and body image (4). In fact, women with breast cancer

believe that breast removal is the excision of a body organ, which symbolizes their sexuality, femininity, and motherhood (5).

Apparent changes in women’s body image are accompanied by negative psychological consequences (6). A person's mental image of oneself is implicitly manifested in one’s value responses and  Since a person’s perception of his/her body has a great impact on his/her character and behavior, a negative body image leads to negative psychological effects, which inevitably affect one’s mood and interpersonal relationships (7).

Body image includes conscious and non-conscious ideas and feelings about one’s body; in other words, it is a concept composed of personal feelings about body size, sex, and body function and ability to attain certain goals (8). Although body image is of great importance among both men and women, it has a special place among women, considering the current social standards which place significant emphasis on women's beauty.

Many studies have revealed women’s considerable dissatisfaction with their body size and shape (9, 10). Therefore, women are highly exposed to the risk factors for body image distress (11, 12). Previous research has shown that a negative body image has devastating impacts on public health and one’s self-esteem, activity level, and social participation; moreover, it may ultimately lead to depression and social isolation (13).

The body image that people have of themselves even affects their behaviors (14). Removal of one or both breasts is often associated with changes in mental image, reduced sexual attraction, anxiety, depression, feelings of hopelessness, feeling of being dismembered, guilt, fear of recurrence, rejection, and eventually suicidal tendencies (5).

Ghorbanian and Abdollahzade in their study showed that 100% of women with breast cancer, who had undergone mastectomy, were reported to have a negative image of their bodies (15). However, in this regard, Naghipour et al. (16) in a causal, comparative study showed no significant difference between the general population and breast cancer patients (undergoing mastectomy and breast surgery) in terms of body image.

In this regard, some researchers noted the importance of quality of life in patients with breast cancer and studied this factor as an important component in such patients. Four variables including family background, socioeconomic status, and physical and mental status can both dependently and independently affect the quality of life (17). One’s perception of quality of life can also affect each of these mentioned variables (18).

Cancer causes many mental stressors that can significantly affect quality of life and almost every aspect of one’s life (18, 19). Researchers with an objective approach have considered different factors related to life standards including physical health, personal status (e.g., financial level and life status), social communication, and occupational status (20).

The performed research on women with cancer showed that women, who were newly diagnosed with breast cancer, obtained lower scores on quality of life, compared to women without breast cancer (21).  In a study by Hassanpour and Azari (22), performed on 200 cancer patients, quality of life was undesirable in 34% of the studied patients and desirable in 66%.

 It seems that poor body image in patients with mastectomy can affect their quality of life. Despite the importance of identifying psychological problems and mitigating these problems, very few studies have been conducted in this regard. Several studies have focused on each of these variables and most of them have examined the relationship between these variables and other health components (6, 21, 23, 24, 25). Also, limited research has compared these variables among female patients with breast cancer and healthy women.

The aim of this study was to evaluate the differences and the relationship between body image and quality of life in women with breast cancer and healthy female subjects.

Materials and Methods

In this causal, comparative, cross-sectional study, the population consisted of female patients with breast cancer (n=50) and healthy women (n=50), selected via convenience sampling in Mashhad, Iran. The researchers visited the oncology clinic of Imam Reza Hospital, and due to the limited number of individuals willing to cooperate, 50 female patients with breast cancer and 50 healthy women, who had referred to the clinic, were selected as the study sample.

The inclusion criteria were as follows: 1) being married; 2) non-menopause; 3) non-pregnancy; 4) complete unilateral mastectomy; and 5) non-chemotherapy patients.

After receiving permission from the university authorities, the researcher referred to the oncology clinic of Imam Reza Hospital. After providing a commitment to the clinic, the study samples were selected. The objectives of the study were explained to the participants, and the questionnaires were distributed among them. They were asked to carefully read the questions and select the answers which best suit their features.

Demographic characteristics including age, gender, and education level were collected using a questionnaire.

For the assessment of body image, Multidimensional Body-Self Relations Questionnaire was utilized. This questionnaire consists of 46 items including a number of statements regarding individuals’ thinking methods, feelings, and behaviors, and was revised (26) by Kash. The subjects answered the questions, based on a 5-point Likert scale (strongly disagree= 1 to strongly agree=5). Questions number 6, 11, 12, 15, 17, 21, 22, 23, 26, 28, 29, 31, and 32 were reverse-scored.

After reversing the score of these items, the score of each subject in 6 subscales was calculated, based on the sum of items related to each subscale. This subscale included appearance evaluation, appearance orientation, fitness evaluation, fitness orientation, mental or subjective weight, and body part satisfaction. In the Farsi version of this scale, Cronbach's alpha coefficients for each subscale were reported as 0.88, 0.85, 0.83, 0.79, 0.91, and 0.94 in a sample of 217 students, respectively; these values indicate the internal consistency of the questionnaire.

Correlation coefficients between the scores of 67 cases at two points in time (with a two-week interval) were as follows: 0.78 for appearance evaluation, 0.75 for appearance orientation, 0.71 for fitness evaluation, 0.69 for fitness orientation, 0.84 for subjective weight, and 0.89 for body part satisfaction; these values indicate the high reliability of this scale (27). Moreover, the validity of this questionnaire has been confirmed in foreign studies and its reliability in a sample of women with cancer varied from 0.62 to 0.85 (28).

In a study performed by Kash in 1994, cited by Asar Kashani et al. (29), internal consistencies of appearance evaluation and body part satisfaction were 88% and 77%, respectively. Also, the validities of appearance evaluation and body part satisfaction were 81% and 86%, respectively; it should be mentioned that validity was evaluated twice.

The subjects’ quality of life was evaluated by Short-Form Health Survey Questionnaire (SF-36). This self-report questionnaire, which is mainly used to assess one’s quality of life and health status, was first designed by Weir and Shrion (30). This questionnaire contains 36 statements and 8 domains including physical function, social function, physical role functioning, emotional role functioning, mental health, vitality, body pain, and general health. The sum of subscale scores indicates the total score of one’s quality of life.

The items were scored using a Likert scale, ranging from 1 to 6; higher scores indicated higher quality of life. Validity and reliability of SF-36 have been confirmed in Iranian population, and internal consistency coefficients of its 7 subscales range from 77% to 95% (65% in the domain of vitality) (31). Moreover, the reliability of this questionnaire has been evaluated, and Cronbach's alpha ranged between 0.51 and 0.77; moreover, the validity of the questionnaire was confirmed (32).

For data analysis, descriptive statistical indices including frequency, percentage, mean, and standard deviation were used. To evaluate our hypothesis, Pearson’s correlation and independent t-test were performed to determine the differences between the two groups. Data were analyzed, using SPSS version 16.

Results

In this section, descriptive indicators of the studied variables are discussed. At first, patients’ demographic characteristics and descriptive indicators of the studied variables are analyzed. According to the obtained results, the mean age of patients with breast cancer was 32.0 yrs (SD=0.5), and the mean age of healthy subjects was 33.7 yrs (SD=4.2). Also, the majority of the subjects in both groups had secondary level education (P>0.05, χ²=2.04). Among cancer patients, 70% were housewives and 30% were employees. Also, among healthy subjects, 60% were housewives and 40% were employees (P>0.05, X²=1.09).

As the assessment of body image and its components in the two groups indicated, subjective weight had the lowest mean (mean= 4.34, SD=0.74) among the other components of body image. On the other hand, the mean score of body image in patients with breast cancer was 109.9 (SD=±19.0), which was lower than that reported in healthy subjects (mean=120.2, SD=±19.8).

As the descriptive evaluation of quality of life in the two groups indicated, the mean score of quality of life was 11.2±73.3 in cancer patients and 10.3±82.4 in healthy subjects; in all components, the mean scores of cancer patients were lower than those reported in healthy subjects.

There was a significant difference between patients with breast cancer and normal subjects in terms of body image and its components, with the exception of  appearance evaluation (P=0.05, t=1.9) and appearance orientation (P=0.06, t=1.8). The P-values of other components are as follows: total body image (P=0.01, t=2.6), fitness evaluation (P=0.001, t=3.5), fitness orientation (P=0.02, t=2.3), subjective weight (P=0.001, t=7.11), and body part satisfaction (P=0.004, t=2.9) (Table 1).

The results showed a significant difference between the groups in terms of total quality of life (P<0.001, t=4.1) and its components including physical function (P=0.01, t=2.0), social function (P=0.001, t=6.4), physical role functioning (P=0.001, t=8.7), emotional role functioning (P=0.01, t=2.4), psychological health (P=0.01, t=8.6), vitality (P=0.001, t=3.8), body pain (P=0.001, t=5.2), and general health (P=0.001, t=6.8) (Table 2).