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

Abstract 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.

negatively affect cancer progression and survival rates, 6,7 pointing towards the need for adequate psychosocial interventions targeting appearance-related side effects to improve psychological outcomes.
Over the past decades, numerous group-based psychosocial education programs have been put forward to overcome psychological distress related to breast cancer treatment. 8 One of these interventions is skin and camouflage treatment, which directly addresses changes in appearance by teaching skin care and applying makeup.
The effectiveness of makeup to improve psychological outcomes has been supported recently in patients with head and neck cancer, 9 showing that symptoms of depression and anxiety were reduced, and body image was increased up to 3 months after treatment. Similarly, beauty care was found to immediately decrease anxiety and increase self-image in a heterogeneous sample of cancer patients, particularly in those reporting appearance-related side effects at the time of intervention. 10 Research on the immediate and short-term effects of beauty care interventions in breast cancer patients, however, is less clear: It was consistently found that perception of attractiveness was improved, and symptoms of depression and anxiety were immediately decreased by beauty care. [11][12][13] While these results support the idea that beauty care has beneficial effects on psychological outcomes on the short term, no conclusions can yet be drawn about their specificity, reliability, and stability because of a lack of control groups (including randomized assignment), low-sample sizes, and short or absent follow-ups.
The few studies that examined both short-and longer-term effects of beauty care produced mixed findings. For example, although beauty care treatment increased body image satisfaction after surgery, these improvements did not persist to 3 months later. 14 Similarly, immediate decreases in distress and increases in stress coping have recently been documented, 15 but no differences were found at 1-month follow-up.
Initial evidence indicates, however, that beauty care may improve facets of quality of life midterm to the effect of a higher selfconfidence and optimism even after the end of radiotherapy. 16 Previous research suggests that beauty care for reducing appearance-related side effects has an immediate beneficial effect on a range of psychological outcomes (eg, symptoms of depression, quality of life, self-esteem, and body image satisfaction). However, results are still inconclusive regarding the stability of these improvements. In the current study, 39 primary breast cancer patients with appearance-related side effects were randomized to an immediate intervention group (IG) or wait-list control group (WL) and completed trait questionnaires on symptoms of depression, quality of life, body image, and self-esteem at four measurement points (ie, baseline and 2, 4, and 8 weeks after baseline). The intervention consisted of a single-session group makeup workshop. In addition to the methodological improvements compared with previous studies, we also incorporated a portrait and upper-body photo shooting. Photos were also professionally edited and sent to the patients, which may have a favorable effect on study outcomes as well. On the basis of previous findings, we hypothesized that there would be immediate and shortterm decreases in symptoms of depression and increases in quality of life, body image, and self-esteem for IG but not for WL. Furthermore, we expected stability of improvements on psychological outcomes after 8 weeks.

| Participants
Eighty-four women with a diagnosis of early breast cancer were recruited through in-hospital advertisement at the Breast Center of the Ludwig Maximilian University of Munich, Germany. Sixty-one patients were screened for the following inclusion criteria: primary breast cancer, 18 years old and above, reporting appearance-related side effects of cancer treatment (eg, irritated or pale skin, loss of scalp hair, eyebrows, or eyelashes), and time since diagnosis less than 24 months. Forty-four eligible participants were randomly allocated to either IG or WL (see Figure 1 for participant flow and dropout).
Descriptive statistics of the final sample are shown in Table 1.  Intervention credibility. Participants were asked whether they deemed the approach of the intervention to improve well-being in breast cancer patients as reasonable, whether they felt confident that the intervention will improve their own well-being, whether they would recommend the intervention to a friend suffering from cancer, and as control item, whether they felt confident that the intervention will help to overcome general health problems (eg, insomnia and headaches). Items were rated on an 11-point Likert-type scale (0 [not at all] to 10 [very much]).

| Procedure
Breast cancer patients with appearance-related side effects of cancer treatment were informed about the study by the breast care nurses.
Interested patients were screened for eligibility and were then randomly allocated to IG and WL, respectively. All patients completed a set of questionnaires at four times: baseline, posttest 1 (2 weeks after baseline), posttest 2 (4 weeks after baseline), and follow-up (8 weeks after baseline). Five weeks after baseline, WL entered active treatment and passed through the same procedure as IG, that is, receiving the intervention (5 weeks after baseline) and completing posttest 1 (6 weeks after baseline), posttest 2 (8 weeks after baseline), and follow-up (12 weeks after baseline). Demographic and clinical variables were collected at baseline.

FIGURE 1
Flow of participants during the study. Wait-list control entered active treatment 5 weeks after baseline and between-group comparisons were conducted for baseline, posttest 1, and posttest 2. Follow-up assessment was used to examine the stability of treatment effects 8 weeks after baseline. Numbers in squared brackets indicate that the WL completed posttest 1 and 2 for a second time after receiving the intervention The intervention for IG took place 1 week after baseline and consisted of a single 4-hour makeup workshop and photo shoot at a makeup school. Participants completed the STDS immediately before the intervention. They were then trained by professional beauty specialists and were introduced to useful skills, including skin care and the use of makeup to cover appearance-related side effects. Two different makeups were applied, after which participants were encouraged to participate in a portrait and upper-body photo shoot, respectively. Participants then completed the STDS for a second time and were asked to rate the credibility of this intervention. Finally, they received their professionally edited photos 2 weeks after intervention by e-mail (after completing posttest 1 but before completing posttest 2). All makeup workshops were conducted as a part of the publicly available "Recover Your Smile" program (www.recoveryoursmile.org).

| Statistical analyses
Pearson's χ 2 tests or Fisher's exact tests for categorical variables and independent samples t tests for continuous variables were conducted to test for between-group differences in demographic and clinical variables at baseline (Table 1)

| CONCLUSIONS
This study aimed at investigating the immediate, short-term, and midterm effects of a beauty care intervention on symptoms of depression, quality of life, self-esteem, and body image in patients with early breast cancer.

| Clinical implications and conclusions
Results of the current study show that psychological outcomes can be improved through a relatively brief and low-cost beauty care intervention in breast cancer patients reporting appearance-related treatment side effects. Specifically, the current intervention decreased symptoms of depression and improved quality of life and self-esteem immediately and in the midterm. As psychological variables have previously been linked to long-term medical outcomes (eg, mortality rates), 22,23 beauty care as an integral part of supportive breast cancer treatment may promote medical and psychological adjustment to disease. Therefore, future studies may investigate whether beauty care interventions could have beneficial effects on medical outcomes and whether these are mediated by improvements in psychological (eg, depression and self-esteem), behavioral (eg, treatment compliance), psychophysiological (eg, [para-]sympathetic activation), 24 or psychoendocrinological (eg, cortisol and oxytocin) variables.
As appearance-related side effects are commonly experienced by the majority of breast cancer patients, the current intervention is recommended to these patients to cope with the distress during medical treatment. In contrast to other supportive care treatments, the current intervention takes place outside a hospital setting and may, thereby, foster distraction from inpatient cancer treatment. To conclude, by demonstrating positive effects on a range of psychological outcomes and by yielding a high credibility among patients, the current study suggests the use of this type of brief, low-cost psychosocial intervention in women undergoing medical breast cancer treatment.