BODY IMAGE AND CANCER
Body image refers to how an individual perceives their body and the way it functions. It extends beyond physical appearance to encompass the person's thoughts, feelings, and behaviors related to the body in its entirety (Fingeret et al., 2012). Therefore, body image reflects the relationship individuals have with their bodies and ultimately influences social roles and interpersonal relationships. Perceptions of body image shift along a continuum between a more accepted or positive body image and body image dissatisfaction or a negative view of the body during times of health as well as during illness or injury as changes to appearance, body structures, or body functions occur (Fingeret & Teo, 2018; Teo et al., 2015). Cancer and its treatment frequently result in alterations to appearance such as hair loss or skin discoloration as well as to body structures and functions when there is a need for a stoma or an amputation of a limb or body part. Such changes are known to induce psychological distress not limited to anxiety, depression, and embarrassment that can shift body image toward body image dissatisfaction (Fingeret & Teo, 2018).
Body Image Dissatisfaction
When a discrepancy or a lack of satisfaction exists between a person's perception of an ideal body and the person's actual body, body image dissatisfaction arises (Fingeret & Teo, 2018). The perceived discrepancy may not reflect the objective reality of the body and may intensify following treatment of cancer where disfigurement occurs such as with orbital exenteration (removal of an eye) or a forequarter amputation (removal of the upper extremity and shoulder girdle) (Fingeret et al., 2012). Individuals with body image dissatisfaction experience distress through (1) the expression of negative thoughts toward themselves, (2) the demonstration of negative behaviors toward themselves including social avoidance or neglecting to care for a body part, or (3) the development of an affective mood disorder such as anxiety or depression that interferes with the person's ability to participate in usual daily activities (Taylor, 2015). Distress related to body image dissatisfaction has become an important predictor of quality of life for those who have undergone cancer treatment where greater body image dissatisfaction predicts a poorer quality of life in adults treated for cancer (Rhoten, 2015). Adverse psychosocial difficulties linked to body image dissatisfaction in patients with cancer including the perceived inability to cope effectively, depression, or anxiety not only reflect the way these individuals see themselves but also how they believe others see them (Rhoten, 2015). Thus, quality of life can be impaired both socially and economically (Fingeret et al., 2014). A person may self-isolate from family or peers to a degree that social roles, interpersonal relationships, and daily routines become disrupted and employment becomes difficult or impossible (Taylor, 2015). Fingeret et al. (2012) found significant associations between body image dissatisfaction and the quality-of-life domains of physical, emotional, social, and functional well-being where distress hindered:
* Daily functions (e.g., self-care tasks and household tasks);
* Physical functions (e.g., participation in exercise and fitness or sports);
* Social functions (e.g., time spent with family, meeting friends, or time spent in public);
* Intimate relationship functions (e.g., meeting a partner or sexual functioning); and
* Occupational functions (e.g., employment or returning to specific work tasks) (Fingeret & Teo, 2018).
When adults who have undergone treatment of cancer sustain a negative expression toward themselves, compensatory behaviors and emotional consequences often develop in accordance with the associated factors of body image dissatisfaction listed in Box 1. Negative behaviors affiliated with body image dissatisfaction also include the reluctance of individuals to participate in screenings for colorectal, cervical, and breast cancers as well as with lower rates of breast and skin self-examinations (Fingeret & Teo, 2018). Adults whose treatment of cancer includes surgical intervention are at risk for experiencing changes leading to immediate functional loss and disfigurement that may exacerbate body image dissatisfaction (Fingeret et al., 2012).
THE IMPACT OF RECONSTRUCTIVE SURGERY
The surgical management of cancer leads to a broad range of changes to the body during or following treatment where reconstructive surgery may be necessary to restore form and function (Fingeret et al., 2012). Common form and function changes to the body associated with reconstructive surgery during cancer treatment are included in Box 2 where any one change can become a significant source of distress for a person at a particular time regardless of the visibility of the change or if the change is temporary or permanent (Fingeret et al., 2014). Reconstructive surgical interventions usually improve defect or disfigurement. They are restorative in nature and meant to enhance quality of life or to help mitigate body image dissatisfaction such as when the appearance of a woman's breasts is restored (Teo et al., 2018). However, Fingeret and Teo (2018) found that "reconstructive surgery does not guarantee better body image outcomes" (p. 109). Many times the process of reconstructive treatment involves multistage procedures, making the adjustment to interim outcomes ongoing. This can be particularly distressing to some individuals for having gone through a surgical procedure where full cosmetic form or function has not yet been restored (Fingeret et al., 2014). When interim outcomes lead to unfamiliar bodily changes coupled with the evidence that the "psychological adjustment to a change in appearance lags consistently behind the physical process of scar maturation and healing," embarrassment, shame, and fear are commonly experienced along with other common body image concerns individuals experience after reconstructive surgery listed in Box 3 (Fingeret & Teo, 2018, p. 70).
In a survey conducted by Fingeret et al. (2014) to screen for body image concerns across various cancer populations (e.g., breast, head and neck, ovarian, rectal, melanoma, sarcoma, and other populations) whose treatment involved reconstructive surgery, results revealed that 95% of participants demonstrated concern, preoccupation with, or avoidance behaviors such as social avoidance due to changes that occurred to their bodies. Seventy-five percent of individuals in the head and neck cancer population, who often undergo highly visible surgical changes, reported concerns or embarrassment over bodily changes as a result of surgery (Fingeret et al., 2012). The potential functional impact on individuals who have visible scarring can be found in Box 4.
Anticipatory body image concerns are those concerns that are related to an impending surgical intervention and are associated with heighted psychological distress and difficulty with postoperative coping (Fingeret & Teo, 2018). Individuals who experience increased presurgical distress tend to have more postsurgical complications and slower, longer recovery times (Fingeret & Teo, 2018). Fingeret et al. (2012) found an association between body image dissatisfaction and the stage of reconstruction where body image dissatisfaction increased significantly after the initial reconstructive intervention and remained notably elevated for at least 1 year postsurgery when compared with preoperative body image. Conversely, individuals in the final stage of reconstruction reported lower levels of dissatisfaction with their body image than those preparing for reconstruction (Teo et al., 2018). Thus, although body image tends to improve over time after reconstructive surgery for most patients with cancer, an important indicator of recovery is regaining acceptance and confidence in the body and how the body works (Taylor, 2015). Therefore, a need remains for the entire oncological team, not just mental health specialists, to recognize and address individual responses to body image changes that impair quality-of-life domains and functional well-being during any phase of the reconstructive process (Fingeret & Teo, 2018).
INTEGRATING BODY IMAGE INTO PRACTICE
Nurses are uniquely positioned to recognize and address body image changes during the reconstructive process through their role in the direct management of surgical sites and opportunities for face-to-face interactions. By recognizing and addressing the maladaptive thoughts, emotions, and behaviors that individuals may display during their reconstructive journey, nurses can assist those with body image dissatisfaction toward a more positive or accepted body image and help improve self-confidence in social situations (Fingeret et al., 2014).
Individuals susceptible to developing detrimental emotional and behaviors consequences when adjusting to body image changes can be found across all stages of reconstruction regardless of cancer type, age, sex, race, marital status, or body mass index (Fingeret et al., 2014). Thus, it can be beneficial for health professionals to familiarize themselves with common misconceptions related to demographic and treatment-related factors that often influence health professional-patient interactions when addressing body image concerns. Commonly held demographic and treatment-related misconceptions associated with body image changes are discussed in Table 1 (Fingeret & Teo, 2018).
Although the majority of patients who undergo reconstructive surgery develop body image concerns at some point during or after treatment, many manage the challenge of body image dissatisfaction without developing maladaptive consequences (Fingeret & Teo, 2018). Factors that may help buffer individuals against the negative effects of adjusting to body image changes are as follows (Fingeret & Teo, 2018):
* Social support: Social support is associated with improved functional well-being and quality of life in patients with cancer.
* Disposition: An optimistic dispositional style compared with a problem-focused or negative view of the world is associated with better coping. Optimistic individuals tend to engage with difficulties rather than avoid them.
* Appearance investment: Both the importance a person places on appearance and the efforts a person makes to enhance attractiveness affect adjustment. Those who make an effort to feel attractive demonstrate better coping with appearance adjustment.
* Appearance preoccupation: Individuals who pay more attention to or are preoccupied with monitoring other people's reactions for fear of judgment about their appearance may demonstrate decreased coping with changes to appearance.
In addition to the need for understanding misconceptions about who may be susceptible to body image dissatisfaction and the factors that may protect individuals from negative effects related to body image changes, nurses should be aware that a general reluctance of oncology health professionals to address body image concerns exists due to (Fingeret & Teo, 2018):
* Time restrictions caused by heavy workloads;
* Underappreciation for the importance of addressing body image concerns;
* Feeling inadequately trained to handle body image issues with patients;
* Uncertainty of how to broach the topic; and
* Other support services and referral sources may not be routinely available.
Lack of time continues to be the most frequently cited barrier for health professionals identifying and managing body image concerns in practice (Fingeret et al., 2014). Another important aspect of the health professional-patient interaction in regard to successfully addressing body image is that health professionals must (1) be consciously aware of their own attitudes about appearance and the importance they place on it, (2) consider any assumptions they make about appearance, and (3) learn not to overgeneralize negative body image concerns that individuals may experience or assume all patients have the same concerns (Fingeret & Teo, 2018). The importance of health care professionals recognizing the tendency to project assumptions and experiences onto the health care professional-patient interaction is illustrated with Robert in Case Vignette 1 (Figure 1).
Assessing Body Image Changes
An individual with body image dissatisfaction may not constantly present with or experience distress. Fluctuations in distress are related to an individual's (1) social support network, (2) reactions of others, and (3) location on the body where reconstruction occurred (Rhoten, 2015). The significance of the location of the surgical area is considered when assessing body image changes with the understanding that different areas of the body vary in personal significance to individuals (Taylor, 2015). Different regions of the body carry both conscious and unconscious meaning that make certain parts of the body more important to a person than other parts such as when a woman loses a breast (Taylor, 2015). The loss of a breast often affects a woman's sense of self, identity, and sexuality (Przezdziecki et al., 2013). Similarly, men who lose a testicle report feeling shame and that the loss affects both their masculinity and their quality of life during intimacy (Fingeret & Teo, 2018). Body image dissatisfaction is more likely to occur in individuals whose cancer affects a valued part of the body as well as in those who place a higher value on appearance (Fingeret & Teo, 2018). Thus, when assessing for body image changes, it is important to inquire about the following (Fingeret & Teo, 2018; Taylor, 2015):
* Social support: Does the person have a safe social network to call upon?
* Significance of body location: What significance does the affected area of the body hold for the individual?
* Coping strategies: What coping strategies does the person use to deal with the reactions of others and stressful events such as a job change or relationship change?
* Emotions: Are negative emotions present as in social anxiety or fear of intimate relationships? Does the person feel shame or self-consciousness not present prior to treatment?
* Thought processes: Does the individual engage in unfavorable thought processes such as fear of judgment or evaluation by others?
* Behaviors: Are maladaptive behaviors present as in hostility, social avoidance, or social isolation? Are compensatory behaviors used such as concealing the affected area of the body?
* Self-perception: Is the person expressing a negative self-perception including feeling unattractive or demonstrating lowered self-esteem? What is the level of importance the person places on appearance? Is the individual satisfied with their current appearance?
* Early indicators: Are any of the early indicators of body image dissatisfaction listed in Box 5 present?
Fingeret and Teo (2018) introduced a framework called the Three C's to guide health professionals in approaching conservations about body image and when assessing body image changes during routine medical encounters. The Three C's include reminding individuals that it is (1) common to experience difficulties with body image due to cancer and its treatments and to engage in open-minded discussion using open-ended questions about the extent and nature of the (2) concerns the person has regarding body image as well as exploring the (3) consequences or impact that any body image changes are having on the individual's quality of life and daily functioning. Examples of phrases health professionals commonly use that can further shame and embarrass as well as examples of open-ended questions helpful when discussing concerns are provided in Table 2. Formal body image assessments and outcome measures developed for patients with cancer also exist and are located in Table 3 along with general body image assessments relevant for use with the cancer population.
Culture and ethnicity also influence body image and need to be considered when assessing adjustment to body image changes. For example, South Asian and Black women in the United Kingdom reported increased levels of body image concerns between 6 months and 5 years post-breast cancer diagnosis when compared with the distress levels of White women (Fingeret & Teo, 2018). Thus, health professionals should seek to understand the impact of differences in values and beliefs that affect how individuals from various cultures and ethnic minority groups adjust to a cancer diagnosis as well as body image and appearance changes (Fingeret & Teo, 2018).
Intervention and Strategies to Address Body Image
Body image is sustained during times of bodily or environmental change through (1) calling upon social support and (2) using effective coping strategies while (3) adjusting the perceived view that individuals hold of themselves and their perception of how they believe others see them (Fingeret & Teo, 2018). Thus, body image-focused interventions challenge appearance assumptions and focus on accepting body image changes and increasing self-confidence in social situations (Teo et al., 2018). Fingeret et al. (2014) found reluctance in patients to mention distress or body image dissatisfaction to their oncologists or surgeons for fear of appearing vain or ungrateful for the care they received. This furthers the need for the entire oncological team to be involved in assessing for distress in order to successfully address maladaptive thoughts, emotions, and behaviors that contribute to distress and body image dissatisfaction. Oncological team members who frequently contribute to addressing body image concerns include psychiatrists, psychologists, oncologists, surgeons, advanced nurse practitioners, physician assistants, nurses, occupational therapists, physical therapists, speech and language pathologists, and social workers. The following common interventions are utilized to address body image concerns (Fingeret & Teo, 2018; Stern, 2016; Teo et al., 2015):
* Viewing the surgical area (in the mirror), via a picture, or objective description where a health professional describes the surgical area using objective terms. An example is, "You have two drains on the right side of your neck. Your incision starts at the bridge of your nose and travels below your right eye to your cheekbone then goes down to your jaw.").
* Handling reactions or strategies for preparedness when handling unsolicited comments, questions, and staring that may come from loved ones, children, and strangers.
* Reestablishment of sociality through identifying a safe social network and using strategies to navigate social reengagement such as graded exposure to strangers and returning to public.
* Addressing life role changes that come due to changes in body structures and functions such as the need to change professions or the inability to conceive children in what is considered the "natural way."
* Optimizing residual use of body structures and functions such as learning one-handed techniques for dressing and cooking after a forequarter amputation of an upper extremity.
* Allowing vulnerability or giving oneself space or permission to mourn the old self.
* Challenging assumptions that contribute to dissatisfaction as in, "No one will accept me as a life partner because I have a colostomy ... don't have nipples ... don't have a testicle."
* Restoration of self-expression or "look good feel good"; such as adaptations to dress that emphasize areas of the body the person is satisfied with.
* Addressing self-confidence in relation to oneself as well as in social situations and relationships. An example is wearing favorite earrings or lipstick that the person feels good about herself when wearing. Another example is exploring new erogenous zones of the body or using a new position during intimacy.
* Coping strategies for stressful events such as returning to work, starting a new job, or entering into a new intimate relationship.
* Cognitive restructuring techniques:
* Reframing: Refocuses negative thought processes; an example is when a person first views their surgical area and comments that they look "bad" or "ugly" and the health professional refocuses them on what they are seeing instead: swelling and incisions that will not stay the same but will continue to change in a positive way due to healing.
* Normalization: Utilization of the first of the Three C's that reminds a person that it is normal or common to have concerns about body image when changes to the body have occurred.
* Mindfulness: Acceptance techniques such as meditation, breathing exercises, and guided imagery that focus on capturing negative thoughts and feelings and replacing them with more positive or neutral ones.
Interventions that nurses can incorporate into practice at the bedside or when performing a dressing change or during clinic or outpatient appointments include (1) viewing; this allows individuals to see positive changes such as decreased swelling to appreciate the overall improvements that will occur during healing. Avoiding early viewing can lead to increased anxiousness and negative thoughts (Fingeret & Teo, 2018); (2) reframing; it is common for health professionals to tell patients they look great immediately after surgery and then have the patient tell their nurse, "My surgical team keeps telling me I look great. Look at me! I don't look great." An example of reframing would be assisting the patient to consider their stage of recovery and that the surgical team is likely speaking about the healing going well and the surgeon being pleased with the final stage of recovery; (3) normalization; validate that body image concerns are normal or common following reconstructive surgery; (4) "Look good feel good" or restoration of self-expression; encourage individuals to do things within the guidelines of their surgical precautions that make them feel like themselves or feel good about themselves such as wearing a colorful robe or getting dressed in a color complimentary to them, putting on earrings or makeup, or wearing a favorite ball cap. Taylor (2015) suggests explaining to patients that adjusting to changes to body image and adapting to a new body can sometimes take longer than expected and that it is common for improvement to seem slow. Online resources for an individual seeking support are provided in Table 4. The individual can also be referred to a mental health specialist with training in addressing body image if functional well-being and quality of life continue to be disrupted. Sharon in Case Vignette 2 provides an example of interventions used during acute postoperative recovery care (Figure 2).
CONCLUSION
The majority of adults who undergo reconstructive surgery for the treatment of cancer develop some degree of body image dissatisfaction during the reconstructive process regardless of the visibility of the change to the body or if the change is temporary or permanent. An important indicator of recovery after surgery remains regaining acceptance and confidence in the body and how the body works while distress related to body image dissatisfaction predicts diminished quality of life and functional well-being. Although the entire oncological team should seek to understand individual responses to body image changes and have the ability to recognize and address distress related to body image dissatisfaction during the reconstructive process, nurses are uniquely positioned through their direct management of surgical sites and opportunities for face-to-face interactions to help reduce the stigma, shame, and embarrassment associated with body image dissatisfaction and to improve self-confidence in social situations.
REFERENCES