Body image screening for cancer patients undergoing reconstructive surgery

Body image is a multidimensional construct involving perceptions, thoughts, and feelings about the entire body and its functioning.1 It is recognized as a critical psychosocial issue for cancer patients undergoing reconstructive surgery because they are at high risk of experiencing disfigurement and functional impairment. The process of adjusting to bodily changes during reconstructive treatment is ongoing, as multi-staged procedures are often required. Interim outcomes may be particularly bothersome to patients when cosmetic form and function have not been fully restored. Among the adverse psychosocial difficulties linked with body image disturbance in cancer patients include depression and anxiety2–6, sexual functioning difficulties7–10, and impairments in overall quality of life11–13. High rates of body image concerns have been documented for head and neck and breast cancer patients, two groups who most often undergo reconstructive surgery. Body image disturbance is among the most common psychosocial concern reported by women with breast cancer.14 Moreover, up to 75% of patients with head and neck cancer have been found to endorse concerns or embarrassment about bodily changes following diagnosis.15,16 It is difficult to estimate rates of body image concerns among cancer patients undergoing reconstructive surgery as most research on body image and cancer has either been conducted with disease-specific samples or with a particular subgroup receiving reconstruction (i.e., breast reconstruction). The vast literature reviewing patient-reported outcomes in breast reconstruction identifies various demographic (e.g., age, marital status)17 psychological (e.g., depression, anxiety)5,18, medical (e.g., body mass index)19 and disease/treatment related factors (e.g., cancer type, type and timing of reconstruction, complications)20–22 associated with body image and quality of life. Increasing attention is being given to delivering psychosocial care to cancer patients which specifically targets body image difficulties. Much of this work is based on cognitive-behavioral models of body image disturbance which highlight the importance of addressing maladaptive thoughts, behaviors, and emotions related to one’s appearance.23–25 For a patient struggling with body image concerns, emphasis is placed on acceptance of body image changes and increasing self-confidence in social situations. Key treatment strategies for mental health specialists to manage body image issues in the oncology setting have been described elsewhere,26–29 and it is recognized that treatment should be tailored based upon the distinct phase of the cancer journey. A significant source of distress for cancer patients undergoing reconstructive surgery is related to body image changes they experience during treatment. Unfortunately, much research suggests that physicians are not adept or comfortable with evaluating or managing patient distress. Lack of time is the most frequently reported barrier for medical professionals in being able to identify and manage patient distress.30 Moreover, patients are reluctant to bring up their distress with their oncologists31,32 and this may especially be true for those experiencing body image concerns. It is not uncommon for a cancer patient to worry about being seen as “vain” and experience shame and embarrassment about having body image concerns.26 For these reasons, it is critical to develop a useful screening tool that will facilitate the identification and treatment of patients with body image difficulties in the oncology setting. Validated tools assessing body image in cancer patients are lacking, and we are not aware of any tools developed for the purpose of screening patients for body image. A systematic review by Annunziata et al., found only six questionnaires dedicated to body image assessment for cancer patients. Only one tool was applicable to patients with diverse disease sites, while remaining tools were specific to breast or gastrointestinal cancer.33 None of these tools were identified as offering a gold standard for evaluating body image in the oncology setting, nor were any specifically developed as a screening tool. More recent advancements have been made with the development of assessment tools for breast cancer patients undergoing reconstructive surgery, focused on satisfaction with outcomes and quality of life. Tools such as the Breast Reconstruction Satisfaction Questionnaire (BRECON-31)34 and Breast-Q35 have gained more widespread use, and have undergone extensive validation. However, these tools focus on a specific subset of patients undergoing reconstruction, and again are not intended for use as a screening measure of body image distress. Our goals were to design and evaluate a brief body image screening tool for cancer patients undergoing reconstructive surgery that has the potential to be used as part of routine clinical practice. This tool is needed to assist medical professionals in identifying patients with body image distress who may benefit from a referral for specialized psychosocial care.