In the remainder of this article, we propose practical strategies for the oncologic health care team when addressing body image concerns. We are aware of only one study that focuses on patient-physician communication about body image changes related to cancer. However, the health care communication literature supports certain key skills and strategies that are undoubtedly as applicable to body image concerns as they are to other emotional issues. Strong evidence suggests that we can help our patients overcome fear, embarrassment, anxiety, and other negative emotions by following patient-centered approaches to challenging conversations. We discuss these approaches below.
With Whom Should We Discuss Body Image Concerns?
Because body image concerns are widespread among cancer patients and associated with significant adverse psychosocial outcomes, it would be ideal to discuss body image with every patient during each encounter in the same way we reconcile medications. However, such a universal approach is not feasible in busy clinical practices. We therefore recommend that clinicians focus on patients who are most likely to develop body image concerns, namely those whose disease or treatment cause significant self-perceived changes in physical appearance or function.
Available research points to patients who undergo mastectomy and head and neck surgery as having a high prevalence of difficulties adjusting to body image changes.[10-15] In addition, patients who undergo ostomy placement also develop body image issues.[21-23] We should discuss body image with patients who undergo treatment for gynecological, testicular, or prostate cancer, because surgery and other treatments affecting sexual organs have both functional implications and strong symbolic significance related to masculinity/femininity.[32-34] Limb amputation resulting from cancer treatment is also likely to result in significant body image issues, with research demonstrating heightened body image difficulties especially for patients undergoing late amputation (that is, after a failed limb-salvage procedure).
Regardless of a patient's diagnosis, we should address body image concerns with those who voluntarily raise concerns or who behave in ways that indicate body image difficulties. Each indicator listed in Table 2 corresponds to dysfunctional thoughts, maladaptive behaviors, and/or negative emotions, according to the cognitive-behavioral framework discussed throughout this article. Some patients may develop body image concerns that interfere with treatment, such as the patient who declined treatment for rectal cancer described briefly at the beginning of this article. Other body image difficulties become evident following treatment, such as the breast cancer patient who avoids viewing herself postoperatively and refuses to allow her husband to view her breasts. Body image problems can also persist into survivorship, as reflected by ongoing distress, anxiety, or depression. If left untreated or unrecognized, the patient with debilitating anxiety about returning to work and engaging in social situations following a partial glossectomy may ultimately become reclusive and be unable to resume routine activities. Considering the subjective nature of body image,[1, 2] even a patient whose functioning and appearance changes seem minimal can still experience significant body image difficulties. Many patients are embarrassed or ashamed to voluntarily mention their body image concerns.[2, 52] We should therefore proactively inquire about body image if we suspect an issue, even if the patient does not mention it.
Table 2. Potential Indicators of Body Image Difficulties
|• Unrealistic expectations about treatment outcomes for appearance and functioning|
|• Preoccupied with concerns about upcoming appearance changes|
|• Difficulties making treatment decisions due to concerns about appearance/body changes|
|• Difficulties with or avoidance of viewing oneself after treatment|
|• Highly dissatisfied with appearance outcome following treatment|
|• Preoccupied with perceived or actual physical flaws resulting from cancer and/or its treatment|
|• Avoidance of social situations due to appearance/body changes|
|• Romantic relationship distress due to body image changes|
|• Considerable time and effort spent in appearance-fixing behaviors|
|• Persistent distress, anxiety, or depression due to body image changes|
A Framework for Discussing Body Image Difficulties: The Three C's
Fingeret proposed a conceptual framework for approaching conversations about body image, which is referred to as The Three C's. This strategy encourages patients to discuss their body image concerns, thereby allowing the health care team to identify emotional difficulties and problematic behaviors associated with these concerns and develop a plan to address them. At the beginning of a clinical encounter, providers should remind patients that body image difficulties are very common as a result of cancer and its treatment. Normalizing concerns in this way reduces shame, embarrassment, and stigma. We should then ask patients what specific concerns they have related to body image. These may include concerns about effects of impending treatment or about recent or prolonged changes to appearance and/or functioning. This step is accomplished with open-ended questions that elicit patient narrative. Finally, we should ask patients about consequences of their body image difficulties, or impact on daily functioning. We should be especially attuned to problems with social, emotional, and occupational functioning.
Principles of patient-centered communication are critical for addressing body image concerns. Open-ended questions and phrases, such as “Tell me more” and “What is that like for you?” encourage expression. Many people think of communication as talking and educating, but listening well is arguably the most powerful aspect of effective communication. Creating space in the conversation by allowing for silence encourages expression and often yields highly significant if not profound information about patients' values, fears, and goals.[53-55] Interjecting brief phrases without actually interrupting shows patients we are tuned in (eg, “What else?”, “I see…”). Listening is highly therapeutic, because all people have a need to be heard, especially those who are scared and vulnerable, such as cancer patients.[52, 53, 56] Health care providers, especially doctors, tend to do most of the talking in an attempt to “educate” patients, pose a series of closed-ended questions, and interrupt patients after only a few seconds. Many doctors worry that allowing patients to express themselves takes too much time. However, encouraging expression typically adds only a few minutes to the encounter and greatly increases the value proposition. In other words, the meeting may take a few minutes longer, but the time investment pays huge dividends in trust, rapport, and patient satisfaction in the short and long term.[49, 52]
Encouraging patients to express themselves invariably creates emotional moments that lead to empathic opportunities.[57-60] Emotional moments can be explicit, such as when a patient cries, says “I'm scared,” or displays anger. Emotional moments can also be implicit, such as when a patient looks sad or anxious without saying so. Many doctors are uncomfortable during emotional encounters, because they become emotional too or do not know how to respond to emotion. Medical training overemphasizes biomedical knowledge at the expense of psychosocial skills, so we tend to try to “fix” problems. Many health care providers offer premature reassurance by saying things like “You look great!” or “Stop worrying, in a few months you will look completely normal.” Others offer a treatment plan rather than simply staying with emotions for a few moments. We should offer reassurance, education, and further treatment options only after patients have had the chance to express their concerns. Table 3 presents a summary of key communication skills and phrases useful for addressing body image concerns.
Table 3. Examples of Communication Strategies for Addressing Body Image Concerns
| ||Body Image Challenge||Typical Approaches||Preferred Approaches|
|Exploratory Phrases||Empathic Phrases|
|Example #1||“I can't stand to look in the mirror or show my body to my husband since my mastectomy.”||Premature reassurance:You look great! Don't worry, your swelling will continue to go down, and things will look even better in a few weeks.||What do you see when you look in the mirror?Have you discussed your concerns with your husband?||This must be a huge adjustment for you, since you used to be more comfortable with your body.|
|Example #2||“I rarely leave the house since my surgery. I don't like when people stare at me or talk about my appearance or garbled speech. I worry about what others think of me, especially my grandkids.”||CheerleaderYou need to get out more, and you will feel better.Your family needs you and loves you just the way you are.||What do you think your grandkids think of you now?Do you think your friends and family miss seeing you?||You obviously love your grandkids tremendously.It must be very difficult for you to not spend time with them like you used to.|
|Example #3||“I had beautiful hair down to my waist before I started chemotherapy. I can't stop crying about my hair falling out.”||CheerleaderDon't give up! You're nearly done with chemo.||Tell me more about what this is like for you.Do you have any close friends or family you feel comfortable talking to about your concerns?||I know how much pride you take in your appearance, so this must be very difficult for you.|
| || || || || |
|Example #4||“There is no way I'm getting a (colostomy) bag. Everyone will be able to see it through my clothes, and my wife will never sleep with me again.”||Premature reassuranceOstomy bags these days are easily concealable beneath your clothes.||Tell me more about your concerns Have you discussed this issue with your wife?||I can imagine the thought of a colostomy bag must be shocking and can be difficult to accept at first. I understand that you have a lot of concerns.|
| || ||Education, scare tactic|| || |
| || ||If you don't get proper treatment, you will die of your cancer.|| || |
In addition to The Three C's, there are 4 additional recommendations for the oncologic team to effectively address body image issues. These include: 1) educate patients about what to expect in terms of appearance and functional outcomes, 2) connects patient with relevant community resources, 3) refer patients to a mental health specialist for brief or intensive therapy if needed, and 4) follow up with patients with known body image issues about their concerns at each clinic visit. There are numerous community resources to assist cancer patients in dealing with body image. Two examples of community-based organizations with dedicated programs for cancer patients struggling with body image are the American Cancer Society (the Look Good, Feel Better Program) and Changing Faces. Other organizations such as Cancercare, Cancer Support Community, and Livestrong also provide national support programs that can help address body image issues. Further details about these types of community resources has also been summarized elsewhere.
With regards to referring patients to a mental health specialist, Table 2 offers potential indicators to signify the need for a referral. There are various intervention techniques that well-trained mental health specialists can use to treat body image difficulties of patients with cancer beyond those discussed in Table 1. Further work describes, for example, the use of mindfulness-based therapy, acceptance and commitment therapy, expressive writing, and sensory approaches (eg, art, music, and dance therapy) to treat body image dissatisfaction.[66, 67] Such approaches have not been evaluated with cancer patients experiencing body image distress, and thus warrant further study.
Our review of available research on body image and cancer revealed that body image issues affect a wide array of cancer patients and adversely impact quality of life and psychosocial functioning. Body image difficulties appear to be the most prevalent in the immediate postoperative and treatment period. Some research suggests that these difficulties may subside and stay relatively stable after approximately 2 years. However, continued body image problems have been found with long-term survivors, specifically within the breast cancer literature. Several tentative risk factors of body image disturbance have been reported (eg, younger age, higher BMI, specific cancer treatments), but further studies need to be conducted. Intervention research is also limited in this area; however, current evidence supports the use of time-limited CBT interventions delivered by a mental health professional. Other interventions, such as psychosexual therapy, educational-based, cosmesis-focused, sensate-focused, and physical fitness interventions also show some promise but require further study. We identified a number of potential indicators of body image difficulties to facilitate referral to a mental health specialist for body image therapy. However, we also presented key communication skills and strategies that can be used by all members of the oncologic health care team to address body image difficulties during a clinic visit.
We identify a number of future directions for research in the area of body image and cancer. Further data are needed on the prevalence and trajectory of body image concerns as well as on predictors of body image difficulties for patients with different types of cancers. Additional evidence is also needed to support interventions targeting body image difficulties of adult cancer patients. Particular attention must be paid to evaluating interventions delivered in an individual format, because existing work focuses largely on couples or group formats. Finally, significant concerns have been raised about assessment tools currently being used in the literature to evaluate body image outcomes. Moving forward, it will be critical to use validated tools with established clinical cutoff scores that are responsive to change over time with treatment.