Distress and body image due to altered appearance in posttreatment and active treatment of breast cancer patients and in general population controls

Feasibility and acceptability of study methods and psychosocial interventions for body image among women diagnosed with breast cancer: A systematic review and narrative synthesis

OBJECTIVE

This systematic review aimed to summarize evidence for the feasibility and acceptability of psychosocial interventions for body image among women diagnosed with breast cancer and the study methods used to evaluate the interventions in question.

METHODS

Articles were identified via MEDLINE, CINAHL, CENTRAL, PsychINFO, and EMBASE. Inclusion criteria were: (1) peer-reviewed publication in English from 2000 onward with accessible full-text, (2) reported data on the feasibility and/or acceptability of psychosocial interventions and/or study methods, (3) included at least one measure of body image or reported a body-related theme, and (4) sample comprised women diagnosed with breast cancer. All study designs were eligible. Two reviewers independently performed study selection, data extraction, and quality assessment.

RESULTS

Sixty-two articles were included. Participants and comparator groups varied as did interventions. Feasibility and acceptability of the interventions and study methods were inconsistently operationalized and reported across studies. Evidence of feasibility and acceptability was heterogeneous within and across studies, though mostly positive.

CONCLUSION

Published psychosocial interventions for body image and study methods are generally feasible and acceptable. Findings should be used to advance the development, implementation, and evaluation of interventions designed to improve outcomes (body image or otherwise) for women diagnosed with breast cancer.

SYSTEMATIC REVIEW REGISTRATION

This review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42021269062, 11 September 2021).

A Randomised Clinical Feasibility Trial of a Breast Immobilisation Device: The SuPPORT 4 All Bra

AIMS

Despite the breast being a mobile organ, there is currently no standard suitable immobilisation device to optimise radiotherapy for women with larger breasts treated after a wide local excision. The SuPPORT 4 All (S4A) bra was co-designed with patients and radiotherapy professionals. The purpose of this study was to test the feasibility of using the S4A bra in the existing breast cancer radiotherapy pathway.

MATERIALS AND METHODS

A randomised feasibility trial was conducted in a single institution; the primary feasibility endpoint was the recruitment of 50 participants. Efficacy endpoints were also tested, including assessment of skin reactions, dose to organs at risk and patient comfort. Fifty women were randomised to receive either standard radiotherapy with no immobilisation (control) or radiotherapy with the S4A bra (intervention). A separate planning study was undertaken on the cases randomised to receive the S4A bra. Participants in the intervention arm (S4A bra) underwent two planning computed tomography scans, one with the bra on and one without the bra; allowing direct comparison of organs at risk data for S4A bra versus no bra.

RESULTS

All women who started radiotherapy wearing the S4A bra completed treatment with the bra; patient comfort did not change across the 3 weeks of treatment. Positional accuracy using the bra was comparable with existing published accuracy for methods without immobilisation. The mean ipsilateral lung doses showed some improvement when positioning with the S4A bra was compared with the no bra set-up (3.72 Gy versus 4.85 Gy for right-sided cases, 3.23 Gy versus 3.62 Gy for left-sided cases).

CONCLUSIONS

The S4A bra is feasible to use in the radiotherapy pathway with good patient adherence. The S4A bra has potential to reduce dose to organs at risk (specifically ipsilateral lung dose) while maintaining good breast tissue coverage, and improved patient dignity, warranting further investigation on a larger scale.

'Weighing' Losses and Gains: Evaluation of the Healthy Lifestyle Modification After Breast Cancer Pilot Program

Objectives

This pilot study sought to develop and evaluate a novel online group-based intervention (Healthy Lifestyle Modification after Breast Cancer; HLM-ABC) to help breast cancer survivors (BCSs) make healthy lifestyle changes intended to yield not only beneficial physical outcomes (i.e., weight loss, reduced body mass index) but also greater behavioral (e.g., increased physical activity, healthier eating), and psychosocial well-being (e.g., self-efficacy, motivation, body image).

Methods

An exploratory single-arm, mixed-method triangulation design was employed to evaluate the feasibility and preliminary effectiveness of the HLM-ABC intervention for overweight BCSs. Fourteen women participated in the 10-week intervention and completed quantitative measures of the above-mentioned outcomes at baseline, post-treatment, 6-month, and 12-month follow-up time points. Qualitative data were obtained post-treatment via semi-structured interviews and a treatment satisfaction questionnaire.

Results

Participants lost an average of 2.83% of their baseline weight (M = 196.65; SD = 38.59) by 1-year follow-up (M = 191.29; SD = 33.91), equal to a small effect size (d = -0.37). Despite achieving only modest weight loss, participants achieved meaningful gains in the form of increased physical activity (d = 0.2), discovery of gratifying movement, more intuitive eating habits (d = 1.12), greater bodily and emotional awareness, and positive shifts in beliefs about being able to make healthy choices regarding food (d = 0.63) and physical activity (d = 0.38). Furthermore, they demonstrated a slight improvement in body image (d = 0.36) and described feeling more self-compassionate, empowered, and acknowledging of variables beyond control (i.e., hormonal therapy, unsatisfactory surgery) that can present barriers to change.

Conclusion

After completing a 10-week online program, participants achieved meaningful and lasting changes on a number of healthful indicators, even when this did not correspond with a significant reduction in weight. Findings highlight the complex, multifaceted nature of "health" and lend support for promotion of healthier lifestyle following cancer treatment that encompasses not only physical weight, but also behavior, psychosocial well-being, and (often unmodifiable) circumstances such as life-preserving hormonal treatments.

Distress among Korean Cancer Survivors: A Latent Profile Analysis

This study aimed to classify cancer survivors’ latent profile analysis (LPA) according to the problem list and identify the differences in distress between subgroups. Furthermore, this study identified differences between subgroups based on their demographic and clinical characteristics. A self-reported cross-sectional survey was administered to 446 adult cancer survivors in Korea. A distress thermometer and problem list were used, and four domains of the problem list were used to perform LPA and create subgroups. Quade’s non-parametric analysis of covariance was used to determine the difference in distress between the profiles. The three identified subgroups of the problem list were: “low problem group” (36.7%), “high problem group” (49.1%), and “family only low problem group” (14.2%). The analysis showed that there was a difference in the distress level according to the sub-profile of the problem list (F = 43.69, p < 0.001). In interventions for distress, integrative interventions that are not limited to one area are necessary, and cultural characteristics as well as the problem list relevant to cancer survivors should be considered.

Effect of mind and body education on quality of life among young breast cancer patients: a randomized controlled trial

PURPOSE

This study aim was to evaluate efficacy of the combination with cosmetic and psychosocial education program on body image, sexual function, and emotional function among young-onset breast cancer (YBC).

METHODS

An unblended, randomized, controlled trial design was conducted in patients newly diagnosed with stage I-III breast cancer from 2014 to 2015. The intervention group received a structured education program including appearance management and mind control for 4 weeks. The outcome of this study shows effect on body image and sexual functioning and a distress due to altered appearance and anxiety after the intervention and 6 months after intervention.

RESULTS

Among 228 eligible patients, 109 (47.8%) agreed to participate in the present study and were randomized to intervention (n = 54) or control (n = 55) groups. After intervention, the intervention group reported significantly better body image compared to the control group (mean score of 75.0 vs. 59.3, respectively; P < 0.01). The intervention group also reported significantly lower levels of distress due to altered appearance and higher levels of sexual functioning compared to the control group after the intervention. The effects were maintained even 6 months after intervention.

CONCLUSION(S)

Body image intervention for YBC had effect on improving body image and sexual functioning and a reduction in distress due to altered appearance and anxiety. Trial registration number and date of registration: The study was registered at the Clinical Research Information Service (no. KCT0001191, https://cris.nih.go.kr/cris ) on 23 July 2014.

Feasibility and pilot study of a brief self-compassion intervention addressing body image distress in breast cancer survivors

BACKGROUND

The majority of breast cancer survivors (BCSs) experience body image concerns following treatment. Body Image distress (BID) is associated with psychological distress and diminished quality of life. A web-based self-compassion focused writing activity (My Changed Body - MyCB) reduces BID in BCSs, yet limited research exists on participant characteristics associated with such intervention adherence. Self-compassion-based meditations are also efficacious in reducing BID in non-BCS populations. This parallel, double-blind pilot randomised controlled trial aimed to assess the feasibility and acceptability of MyCB, with and without an additional meditation component, on BID and related psychological outcomes in BCSs. The trial was registered with the Australian and New Zealand Clinical Trials Registry (#ACTRN12619001693112).

METHODS

BCSs were randomly allocated to MyCB (n = 39), MyCB + Meditation (MyCB + M) (n = 17) or an expressive writing (EW) active control arm (n = 23). The primary outcome was BID. Secondary outcomes were body appreciation, affect (positive and negative), psychological distress (depression, anxiety and stress) and self-compassion (state and trait). Assessments were completed online at baseline, post-intervention and 1-month.

RESULTS

Adherence to the MyCB writing (45%) and meditation (50%) was modest, and acceptability was high for both MyCB and MyCB + M. Intent to treat linear mixed model analyses indicated: Post-intervention - state self-compassion and positive affect increased for MyCB compared to EW; 1-month: BID scores decreased across all conditions; trait self-compassion increased and anxiety decreased for MyCB + M compared to MyCB and EW.

CONCLUSION

These findings provide preliminary evidence for the efficacy and potential clinical use of the MyCB brief web-based self-compassion intervention alone and with the addition of meditation, to increase self-compassion and psychological wellbeing in BCSs.

Body image, internalized stigma and enacted stigma predict psychological distress in women with breast cancer: A serial mediation model

AIMS

To investigate the roles of total stigma, enacted stigma, and internalized stigma in the prediction of psychological distress among breast cancer patients, and to evaluate the mediating effect of body image in this process.

DESIGN

Cross-sectional.

METHODS

Between Oct-2014 to May-2015, a cross-sectional study was conducted with participation of 223 patients from three cancer centres located in Tehran, Iran. The study variables were assessed using the stigma scale for chronic illnesses 8-item version (SSCI-8), body image scale (BIS), and depression anxiety stress scale (DASS-21). Structural equation modelling using MLR estimator was employed based on the two-step procedure to validate both the full measurement models and the structural models. Five models were tested to determine predictability of all stigma constructs for psychological distress, including stress, anxiety, and depression, through the mediation of body image. Three equivalent models were further examined to re-evaluate the direction of the relationships.

RESULTS

Psychological distress and body image were largely predicted by total stigma, enacted stigma, and internalized stigma. The effect of stigma on psychological distress was mediated through body image. In a serial mediation model, the significance of the pathway of enacted stigma > internalized stigma > body image > psychological distress was confirmed. The serial model in which internalized stigma precedes body image was also supported by the equivalent models.

CONCLUSION

Stigma has been identified as a major source of psychological distress among women with breast cancer. Enacted stigma not only psychologically disturbs the patients but also triggers a chain of other identity transformations (i.e. internalization of stigma and distortion of body image), their ultimate result being a full-blown psychological distress.

IMPACT

Both enacted and internalized stigma distorts breast cancer patients' perception of their body image, which in turn renders them psychologically distressed. The serial process of enacted stigma, internalized stigma, and body image plays an important role in perpetuating distress in these patients. To break this chain of psychological consequences and for interventions to have a greater impact on overall well-being of patients, the effect of enacted stigma on distress via the sequence of two mediators needs to be specifically targeted at each stage.

Emotion regulation and psychological distress in cancer survivors: A systematic review and meta-analysis

Emotion regulation may affect the levels of psychological distress of cancer survivors, but inconsistencies exist among studies regarding the direction of this effect. The systematic review and meta-analysis sought to estimate the associations between emotion regulation patterns (repression, suppression, experiential avoidance and cognitive reappraisal) and psychological distress among cancer survivors. Fifteen studies met inclusion criteria for systematic review, and seven studies focussing on suppression were included in the meta-analysis. The systematic review pointed to a marked variability in associations among the emotion regulation patterns and psychological distress. The three meta-regressions of the relationships between suppression and psychological distress found significant fixed- and random-effect sizes (except marginal significance of a random-effect model for partial correlation). Subgroup analysis showed no moderation effect of time since diagnosis or study quality, but a significant difference (fixed-effect model only, p = 0.005) was found between correlative studies and those controlling for confounders. The current study suggests that suppression is related to elevated levels of psychological distress among cancer survivors, although large inconsistencies exist among studies and publication bias could not be ruled out. Further studies with large samples and a consistent approach are thus required to evaluate the associations of emotion regulation patterns and psychological distress.

A scoping review of measures used to assess body image in women with breast cancer

OBJECTIVE

The emergence of body image studies in the oncology setting has led to the use of numerous measures to assess different dimensions of body image. The present study is a scoping review of the literature on body image in women with breast cancer to describe: measures used to assess body image in women with breast cancer, dimensions the measures used tap into, and gaps and issues needing attention going forward.

METHODS

Three databases were searched for peer-reviewed original studies that had: (1) full-texts available in English; (2) focused on women with breast cancer; and (3) assessed body image.

RESULTS

The search yielded 3,729 peer-reviewed articles; after screening, 562 articles met inclusion criteria. Of the 88 measures used, 28 were used in more than two studies and analyzed herein. The European Organization for Research and Treatment of Cancer Breast Cancer-Specific Quality of Life Questionnaire constituted the most frequently used measure. Most measures used focused on the affective dimension of body image (n = 24/28, 85.7%), followed by the cognitive (n = 20/28, 71.4%), behavioral (n = 13/28, 46.4%), and perceptual dimensions (n = 13/28, 46.4%).

CONCLUSIONS

This review provides a current summary of measures used to assess body image in women with breast cancer. Although some further development and refinement of body image measures could benefit the field, depending on the questions researchers or clinicians seek to answer, there are many available for use. Future research should use these measures to assess the effectiveness of interventions aimed at improving body image in women with breast cancer across the lifespan.

Patient-centred communication for women with breast cancer: Relation to body image perception

AIMS AND OBJECTIVES

This study aimed to determine the predictive values of patient-centred communication (PCC) and patient's characteristics on the body image (BI) perception in postmastectomy patients.

BACKGROUND

Patient-centred communication has been touted as a means of addressing BI issues, especially for postmastectomy patients.

DESIGN AND METHODS

This predictive correlational study was conducted on 275 surgically treated breast cancer patients admitted to the Oncology Departments of two hospitals in Tabriz, Iran. These patients were selected using a convenience sampling method. The Body Image after Breast Cancer Questionnaire (BIBCQ) and patient-centred communication questionnaire (PCCQ) were used for collecting the data. Descriptive and inferential statistics were applied to the data. Reporting was in accordance with the STROBE guideline.

RESULTS

A multivariable model significantly predicted BI perception in participants using surgery type and time elapsed following surgery. Participants' limitations were significantly affected by surgery type and participants' perception of the nurses' PCC skills. Arm concern was significantly affected by surgery type and nurses' PCC skills.

CONCLUSION

Patient-centred skills in nurse-patient communication are critical for resolving BI difficulties such as arm concerns and limitations regarding the disease and its treatment.

RELEVANCE TO CLINICAL PRACTICE

Patient-centred communication skills can be taught nurses in the clinical setting to help alleviate patients' BI problems.

The patient experience of radiotherapy for breast cancer: A qualitative investigation as part of the SuPPORT 4 All study

Introduction

Breast cancer is a global health problem with 2.09 million cases of breast cancer diagnosed worldwide in 2018. With an increase in breast cancer survival attention has now focussed on the impact treatment side effects can have on the quality of life for women during survivorship. The aim of the SuPPORT 4 All project is to develop a support bra for use during radiotherapy, that can reduce normal tissue toxicity (for women with larger breasts) and provide accuracy, dignity and modesty for all women. The first stage of the project involved a co-design process to understand the current patient experience where no support bra or modesty device is used.

Method

A participatory co-design methodology was adopted. Workshops were held with patient representatives (n = 9) to seek understanding of experience during radiotherapy; a total of three workshops over 4 h. The workshops were audio recorded and framework analysis was adopted to identify key patient experiences.

Results

Twelve categories and twenty-six sub categories were identified specific to patient experience. Patient concerns focussed on information provision, Healthcare Practitioner (HCP) knowledge of breast lymphoedema, lack of choice, experiences of being naked, and feelings of disempowerment.

Conclusions

A number of areas were identified that had negative effects on overall patient experience.

Implications for practice

Practitioners should consider patient dignity when configuring services to support patient needs regarding undressing, outside or inside the linear accelerator room. Additionally, practitioners should have an understanding of the impact permanent tattoos may have on some patients’ wellbeing and the impact that breast lymphoedema has on patient quality of life. Practitioners should also consider methods to encourage patient empowerment during radiotherapy; supporting patient self-monitoring of side-effects may be one way to facilitate this.

Translation and Factor Analysis of the Stigma Scale for Chronic Illnesses 8-Item Version Among Iranian Women With Breast Cancer

Background:

Cancer stigma is rarely addressed among Iranian population and patients. The current study aimed at translating and examining the construct validity of the stigma scale for chronic illnesses 8-item (SSCI-8) among Iranian women with breast cancer.

Methods:

In the current study, a total of 223 patients aged 19-75 years were recruited from three cancer centers in Tehran, Iran, from 2014 to 2015. Forward-backward translation method was used. The item-total correlation was evaluated. Exploratory factor analysis employing maximum likelihood method and direct Oblimin rotation was conducted. Reliability was assessed using composite reliability (CR). Average variance explained (AVE) was used for convergent/divergent validity.

Results:

The items mean was 1.47 (0.19), the scale mean 11.75 (5.57); the inter-item correlations were positive and significant (P <0.0001). A two-factor solution with seven eligible items (five for enacted and two for internalized stigma) showed the model fitness. The CR for the total scale, as well as enacted and internalized facets was 0.78, 0.89, and 0.79, respectively; the AVE was 0.66 for each latent variable.

Conclusion:

The Persian version of SSCI-7 was found as a reliable and valid abbreviated instrument to assess experiences of enacted and internalized stigma among Iranian women with breast cancer.

Recover your smile: Effects of a beauty care intervention on depressive symptoms, quality of life, and self-esteem in patients with early breast cancer

OBJECTIVE

Medical cancer treatment is often accompanied by appearance-related side effects such as hair loss, skin irritation, and paleness, which can subsequently lead to psychosocial distress. Initial evidence suggests that beauty care interventions may reduce distress and improve quality of life (QoL), body image, and self-esteem immediately.

METHODS

We investigated the effects of a brief beauty care intervention on self-reported symptoms of depression, quality of life, body image, and self-esteem in 39 female primary breast cancer patients with appearance-related treatment side effects. Patients were randomly assigned either to an immediate intervention group (IG) or to a wait-list control (WL). The intervention consisted of a single-session group makeup workshop, a photo shooting, and of receiving professionally edited portrait and upper-body photos.

RESULTS

While groups did not differ regarding any measure at the pretreatment baseline assessment, IG patients reported less symptoms of depression, higher QoL, and higher self-esteem compared with baseline and compared with WL. Follow-up at 8 weeks indicated moderate stability of these improvements.

CONCLUSIONS

In contrast to previous research, results indicate beneficial short-term and midterm effects of beauty care on psychological outcomes in patients with early breast cancer. These results emphasize the utility of this type of brief, low-cost intervention in women undergoing medical cancer treatment in order to improve their well-being.

Permanent Chemotherapy-Induced Alopecia in Patients with Breast Cancer: A 3-Year Prospective Cohort Study

Chemotherapy‐induced alopecia is (CIA) considered temporary; however, some patients report persistent alopecia several years after chemotherapy. Long‐term prospective data on the incidence and impact of permanent CIA is scarce. This article reports the results of a study conducted to estimate the long‐term incidence of persistent CIA in a cohort of breast cancer patients with measurements of hair volume and density before and after chemotherapy.

Background.

Although chemotherapy‐induced alopecia (CIA) is considered temporary, some patients report persistent alopecia several years after chemotherapy. There is, however, a paucity of long‐term prospective data on the incidence and impact of permanent CIA (PCIA). The objective of our study was to estimate the long‐term incidence of PCIA in a cohort of patients with breast cancer whose hair volume and density were measured prior to chemotherapy and who were followed for 3 years after chemotherapy.

Materials and Methods.

Prospective cohort study of consecutive patients ≥18 years of age with postoperative diagnosis of stage I–III breast cancer expected to receive adjuvant chemotherapy at the outpatient breast cancer clinic at the Samsung Medical Center in Seoul, Korea, from February 2012 to July 2013 (n = 61). Objective hair density and thickness were measured using a noninvasive bioengineering device.

Results.

The proportion of participants who had PCIA at 6 months and 3 years was 39.5% and 42.3%, respectively. PCIA was characterized in most patients by incomplete hair regrowth. Patients who received a taxane‐based regimen were more likely to experience PCIA compared with patients with other types of chemotherapy. At a 3‐year follow‐up, hair thinning was the most common problem reported by study participants (75.0%), followed by reduced hair volume (53.9%), hair loss (34.6%), and gray hair (34.6%).

Conclusion.

PCIA is a common adverse event of breast cancer adjuvant cytotoxic chemotherapy. Clinicians should be aware of this distressing adverse event and develop supportive care strategies to counsel patients and minimize its impact on quality of life.

Implications for Practice.

Knowledge of permanent chemotherapy‐induced alopecia, an under‐reported adverse event, should lead to optimized pretherapy counseling, anticipatory coping techniques, and potential therapeutic strategies for this sequela of treatment.