BODY IMAGE IN RELATION TO SELF-ESTEEM IN A SAMPLE OF SPANISH WOMEN WITH EARLY-STAGE BREAST CANCER
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PSICOONCOLOGÍA. Vol. 2, Núm. 1, 2005, pp. 103-116
BODY IMAGE IN RELATION TO SELF-ESTEEM IN A SAMPLE OF
SPANISH WOMEN WITH EARLY-STAGE BREAST CANCER
Dimitra Manos*, Julia Sebastián*, Maria José Bueno*, Nuria Mateos* and Alejandro
de la Torre **
* Universidad Autónoma de Madrid
** Hospital Puerta de Hierrro de Madrid
Resumen Abstract
Aim: Women diagnosed and surgically trea- Objetivo : Analizar la influencia de determi-
ted for early-stage breast cancer were studied nadas variables (sociodemográficas, tipo de
to determine the influence that sociodemogra- cirugía, tratamiento, apoyo social y calidad de
phic variables, type of surgery, amount of social vida) en la imagen corporal y la autoestima de
support, and quality of life had on their body mujeres con cáncer de mama.
image and self-esteem. Método: Sujetos: 54 mujeres diagnosticadas
Method: Subjects n=54; Measures: Self Este- con cáncer de mama (estadio 1). Instrumentos:
em Scale (Rosenberg, 1965), Body Image Ques- Escala de Autoestima (Rosenberg, 1965), Cues-
tionnaire (authors´article) and E.O.R.T.C. (Qua- tionario de Imagen Corporal (autores del artí-
lity of life) (Aaronson et al, 1988) culo) y E.O.R.T.C. (Calidad de vida) (Aaronson
Result and conclusions: Analyses of varian- et al, 1988)
ce showed that married women reported a Resultados y conclusiones: Los resultados
more positive body image than non-married del análisis de varianza ponen de manifiesto que
women, and so did women with a lumpectomy las mujeres casadas, frente a las no casadas, y
versus those with a mastectomy. These varia- las que habían recibido un tratamiento conser-
bles did not relate significantly to the patients’ vador, frente a las mastectomizadas, tenían una
self-esteem, which in turn was found to be hig- imagen corporal más positiva. Por otra parte, las
her in women aged 43-55 years old when com- mujeres de edades intermedias (43-55 años)
pared to younger women. Correlational analy- tenían mayor autoestima que las mujeres más
ses revealed a significant negative correlation jóvenes. También apareció una correlación
between the deterioration of quality of life negativa entre deterioro de la calidad de vida
after surgery and both body image and self- después de la cirugía y autoestima e imagen cor-
esteem. poral.
Palabras clave: Breast cancer, body image, Keywords: Cáncer de mama, imagen corpo-
self esteem, quality of life. ral, autoestima, calidad de vida.
INTRODUCTION motherapy - also produces significant
bodily changes. These changes, due to both
In recent years, special attention has the cancer itself as well as its treatment,
been directed in research at the influence influence negatively the image the patient
that cancer has on body image. Most types has of his/her body(1-3). In many cases, they
of cancer have significant physical reper- also produce affective disorders and chan-
cussions, and the corresponding treatment ges in sexuality and self-esteem(4,5).
- surgical intervention, radiotherapy, che- Among the various types of cancer, bre-
ast cancer has been singled out for its major
Correspondencia: effect on body image(6-8). According to the
Julia Sebastián
Facultad de Psicología. Múdulo2 despacho 27
Universidad Autónoma de Madrid. Cantoblanco This research was supported in part by grants from
28049 Madrid the Ministry of Science and Technology of Spain
E-mail: Julia.sebastian@uam.es (Project BS02000-0045).104 Dimitra Manos et al.
latest data from the American Cancer consequences has been carried out with sub-
Society, more than 180,000 women are jects suffering from breast cancer(15-18).
diagnosed with breast cancer every year in A factor that has greatly complicated the
the U.S., and it is estimated that 1 out of 9 impact of breast cancer on body image has
women will have developed the disease been the fact that the treatment of choice up
before the age of 85. These numbers are until recently was mastectomy, a mutilating
similar in most European countries. type of surgery of an organ closely associa-
In the latest and most predominant pers- ted with feminine body image and sexuality.
pective, body image is viewed as a cons- Studies indicate that this kind of surgery has
truct that refers to what one thinks, feels, been devastating for the body image of the
perceives and does in relation to one’s own patients(19,20). Currently, surgery still seems to
body. Body image is also considered a part be the preferred treatment, but apart from
of the self-concept(9,10). Although the exact mastectomy which removes the entire mam-
definitions of the term self-concept vary mary tissue, the options include lumpec-
greatly, it is generally understood as the sum tomy, also known as conservative surgery.
of the perceptions or references that the per- Also, in the case of mastectomy, some
son has of him/herself and it includes jud- women are offered the possibility of breast
gements on behaviors, abilities or physical reconstruction. The option of having a lum-
appearance(11). Self-esteem is another term pectomy has significantly bettered clinical
related to body image. Self-esteem is consi- results related to body image and sexuality(21)
dered a positive or negative attitude towards although it doesn’t seem to have affected as
one’s self, based on the evaluation of one’s much psychological adjustment(22).
characteristics, and it includes feelings of At the base of the research concerning
satisfaction with one’s self(12). the psychosocial consequences of breast
Keeping in mind the importance that is cancer there is the understanding that can-
placed on physical appearance in women cer and its treatment are powerful stressors
in the majority of cultures, it is easy to that can have negative consequences on
understand why it is that women have the body image and self- esteem(23). It’s impor-
most problems when it comes to body ima- tant to note that there exist mediating fac-
ge. Going a step further, for many women tors that modify the impact of cancer and
self-esteem is based exclusively on their its treatment on body image or self-esteem,
body image and as a consequence their as is the case with most events that are con-
social functioning and interpersonal rela- sidered stressors. These factors include age
tions are affected(13). It becomes even more and other sociodemographic characteris-
complicated when the woman suffers tics, premorbid functioning, the stage of the
physical changes or disfigurement due to an illness and the type of treatment, marital
illness such as cancer. Her perception of her relations, social support received, and indi-
physical appearance when compared to the vidual and socio-cultural percep-
society’s “ideal” might result in a negative tions(24,25,10). The existing literature provides
impact on her emotional attitude and her an array of studies that have examined all
quality of life(14). This is the case with breast of these factors in various combinations.
cancer, a cancer that affects mostly women. The most important variables found to be
Breast cancer has been of special interest related with body image are the following:
to scientific investigation due to its high inci- Type of Surgery. Research on body ima-
dence, its course, its undefined prognosis, the ge in breast cancer patients seems to have
range of the ages affected, and the importan- centered on the differences between mastec-
ce that the corresponding organ has on body tomy and lumpectomy. There have been
image and self-esteem. As a consequence of many studies conducted to show that lum-
these specific characteristics, a great deal of pectomy has psychological and social advan-
the investigation relevant to cancer and its tages compared to radical mastectomy(22,26).Body image in relation to self-esteem 105
It has been found that women that under- tment, and very important advantages in the
go a mastectomy feel less attractive physi- issue of body image and sexual adjust-
cally and sexually, are more ashamed of their ment(22). It is important to note though, that
breasts, and enjoy less their sexual relations these conclusions should always be consi-
than before surgery, while on the other hand, dered taking into account that there are
women who have undergone a lumpectomy other factors that influence these relation-
do not suffer significant changes in these are- ships such as age, the timing of the assess-
as and they feel healthier than patients with ment and the type of adjunct treatment.
a mastectomy(20). Along the same lines, it has Also, it should not be ignored that there also
been shown that women with a total mastec- exist contrary findings, indicating no signi-
tomy have a significantly worse body image ficant differences between the two types of
than women with a partial mastectomy(27). surgery, even in the issue of body image(26).
Also, findings indicate that there is a differen- As a conclusion, there is indication that
ce in sexual adjustment between women that body image is influenced by surgery in an
have had a mastectomy versus those that independent and possibly different manner
have had a lumpectomy, the second having that other aspects of the patient, such as her
a better adjustment(28), as well as a more posi- level of depression or anxiety. Thus, a study of
tive body image(29). body image such as the present that examines
In many cases body image alterations it independently from the patient’s emotional
have been studied alongside emotional changes could produce new findings.
changes in the patients. The combination
Age and Marital Status. There are data
has given a more global perspective of the
that indicate that breast cancer and its treat-
issues that emerge after the diagnosis and
ment have more of an impact on younger
treatment for breast cancer, but it can also
women(29,31,32). It is possible that this pheno-
confuse results as there are reasons to belie-
menon is related to the life-cycle stage the
ve that body image should be separated
patient is at(33,34). For example, Gluhoski,
from other psychosocial issues. It has been
Siekel and Gorey(35) point out that breast
shown, for example, that the psychosocial
cancer patients who are single suffer speci-
sequelae, including depression and anxiety
fic stressors: pessimism regarding future
are not that different in the long term, bet-
relationships, negative body image and
ween women with a mastectomy and those
with a lumpectomy(27-30). When there are impaired sexuality, fear of disclosing illness
differences between the two groups, it to partners, pain of rejection by partners,
seems that at short term, up to 3 months after sense of isolation and inadequate support.
surgery, it is women with a lumpectomy that Although life-stages and the milestones that
suffer the worse consequences, a finding accompany them, such as marriage or com-
contrary to what would be expected(31). The- mitted long-term relationships, usually
se findings imply that body image might correspond to specific age brackets, in
change independently of any possible emo- many cases it is not so. It could be argued
tional alterations. More recent research that marital status or the corresponding life-
explores the changes in body image as a stage the patient is at, and not age itself, is
source of traumatic stress and associates what differentiates the experience of these
them with the changes in attitudes and women in regard to their body image. It is
sexual activities(32). In this view, it is the important to note as well that in various
change in body image that produces impor- other studies of age showed no significant
tant emotional changes, as opposed to relationship to body image(36-39).
being accompanied by them. Social Support. In certain studies, age
Generally, it seems that that there are seemed to interact significantly with the
modest advantages to lumpectomy in the kind of social support received. It has been
areas of psychological and social adjus- shown that in younger women, sexual func-106 Dimitra Manos et al.
tioning and body image, as well as adjust- more, we wanted to examine the relation-
ment to surgery and treatment, depend on a ship among the concepts of body image and
well-functioning marital relationship. For self-esteem.
older women, these aspects depend on the The sociodemographic variables were
existence of an extended emotional support chosen based on the existing literature: age,
network(40). marital status, educational level, employ-
Generally, in most studies centered on ment, living alone, and children. According
social support, it was concluded that it is an to previous findings we expected these six
important factor for psychosocial adjust- variables to be related with the patients´
ment as well as for survival for women with body image. Also, we added to our analysis
breast cancer(41,42). Different sources of sup- the variable of the amount of support recei-
port have been studied, such as family, part- ved, which might interact with other varia-
ner, friends, and medical professionals, as bles and have an effect on body image. As
well as other patients, and they all seemed far as medical variables are concerned, the
important in various ways(43,44). two types of surgery, mastectomy and lum-
Quality of Life. Quality of life has been pectomy were compared. The majority of
studied extensively in relationship to breast research on the topic concludes that this
cancer. Certain studies have centered on the variable significantly affects body image.
effect that the type of surgery chosen for treat- Finally, we examined the relationship of
ment has on one’s quality of life(45-47). In the- body image with quality life, both as a who-
se studies, it was found that women treated le and with individual aspects of it, as those
with breast-conserving procedures had a are measured by the instrument’s subscales.
relatively better adjustment after surgery At a second stage, we analyzed relation-
when compared with women that had had ship between body image and self-esteem.
a mastectomy. Other authors that have To do that, besides relating the two variables
explored the effect that the type of treatment among them, we examined the effects that
has on quality of life(48-50) have found a the other variables – sociodemographic,
better quality of life outcome related with surgery, and quality of life – had on self-
chemotherapy versus radiotherapy, and esteem directly. There was special interest
with lower doses versus higher doses of che- to see if any of these variables affected one
motherapy. Quality of life in women with dimension of the self and not the other one,
breast cancer has also been studied in rela- examining thus previous suggestions that
tionship to body image. It was found that body image and self-esteem might be two
quality of life concerns rank higher in terms dimensions that are strongly associated but
of importance that the question of body independent and sensitive to different
image(38). In general though, there are only factors.
a few studies in which the relationship bet-
ween quality of life and body image is exa- METHOD
mined. One of the possible culprits is that
in many instances the change in body ima- Sample and Procedures
ge is considered an aspect of the quality of
life and it is assessed with a subscale within Participants were 54 women who had
the quality of life instrument. had non-metastatic breast cancer surgery
The aim of the study reported here was to at the Department of Obstetrics and Gyne-
examine any possible relationships between cology of La Paz Hospital in Madrid,
body image in women with early-stage Spain.
breast cancer on the one hand and sociode- The patients were recruited for a larger
mographic variables, social support recei- study designed as a program of psychoso-
ved, the medical variable of type of surgery, cial intervention in women with early-sta-
and the quality of life on the other. Further- ge breast cancer(51). Patients were approa-Body image in relation to self-esteem 107
ched after surgery and asked if they would Measures
voluntarily participate in a psychosocial
support program. Women that agreed to – Sociodemographic data. Age, marital
take part were screened for meeting the cri- status, employment status, educational
teria of the study and those accepted were level, living arrangements and presence of
evaluated. The evaluation took place 10 to children were evaluated through an initial
15 days after surgery and a week before interview.
they went to collect the results of the – Perceived social support was measu-
biopsy. red through the following question: “How
The medical criteria used for inclusion well supported do you feel by the people
in the present study were the following: a) around you?” The possible answers were 1:
be diagnosed with breast cancer for the first not at all, 2: somewhat, 3: enough, 4: a lot.
time, b) not have nodal metastases, c) have This variable measures the subjective per-
less than four infected lymph nodes, in other ception of the amount of support the patient
words a diagnosis of T1, d) receive a treat- received due to her illness.
ment of chemotherapy with CMF and/or – Type of surgery. Medical information
radiation therapy and/or hormonal therapy. about the type of surgery came from the
(Patients that received other kinds of che- patients medical records. The patients were
motherapy were excluded because the fre- separated into two groups, one including
quency of the administration cycles and/or the women that had a lumpectomy with or
the serious side effects impeded their parti- without axillary irradiation, and the other
cipation in the program), e) have no including the women that had a mastec-
psychiatric history, and f) range in age from tomy, again with or without axillary irradia-
25 to 70 years old. tion.
The subjects that participated in this – Self-esteem. The scale chosen to
study ranged in age from 28 to 68 years measure self-esteem was Rosenberg´s Self-
old. Based on the existing literature, we Esteem Scale (SES). This scale consists of 10
wanted to examine how body image chan- items and it is the most widely used instru-
ges in younger versus older women and so, ment to measure self-esteem despite certain
for analysis purposes, they were divided negative criticism. For each item there are
into three age groups: 1 = 28-42 years old four possible answers (not at all, somewhat,
(N= 8, 14,8% of the sample), 2= 43-55 sufficiently, a lot) and it has high internal
years old (N = 34, 63%), and 3= 56-68 consistency at .82 and reliability at .88.
years old (N=12, 22,2%). Most of the – Body Image. One of the most compli-
women were married (N= 43, 79,6%) and cated issues in body image research has been
women that were not married -single, how to assess it. As it has been noted before
divorced, or widowed- were placed in the (52,39), there are conceptual as well as
same group (N= 11, 20,4%). The first group methodological difficulties, because body
in the analysis is referred to as 1, and the image is not a distinct dimension of the self
second one as 2. Most of the women had but it coincides partly with sexuality, as well
children (N=46, 85,2%) and most did not as with the wider concept of self-image. Also,
live alone (N=48, 88,9%). Fort-one of the physical attractiveness, femininity/masculi-
subjects had completed elementary school, nity, and confidence in one’s self can all be
4 had completed high-school, and 9 had important for the concepts of both body ima-
university degrees. Half of them (N = 27) ge and self-esteem.
were currently employed outside the home It has been concluded that a question-
while the other half (n = 27) were not. naire that evaluates body image should con-
Twenty-seven of the patients had been tain items on dissatisfaction with appearan-
treated with a lumpectomy and twenty- ce, loss of femininity or masculinity, avoi-
seven with a mastectomy. dance to look at self naked, feeling less108 Dimitra Manos et al.
attractive/sexually attractive, dissatisfaction – Satisfaction with Medical Care: This
with scar or prosthesis, adverse effects of subscale measures the patient’s level of con-
treatment/loss of body integrity, self-cons- fidence and satisfaction with the medical
ciousness about appearance(52). The authors´ care she received.
Body Image Questionnaire used in the pre- – Subjective Perception of Physical
sent study follows these suggestions and State: This subscale is a subjective score of
includes items on all of these aspects. It was the perception that patient has of her physi-
created by the investigation team of the cal state.
main study(51) and it consists of 12 items. The – Subjective Perception of Quality of
internal consistency coefficient was at .84. Life: This subscale is a score of the woman’s
– Quality of Life. It was measured using perception of her quality of life.
the E.O.R.T.C. (European Organization for – Subjective Perception of Psychologi-
Research and Treatment of Cancer) Ques- cal State: This subscale reflects the subject’s
tionnaire by Aaronson(53). In this study we perception of her psychological state.
used the Spanish adapted version by Toledo, Along with the instrument’s subscales
Barreto and Ferrero(54) with some modifica- we also constructed two more variables to
tions. This questionnaire consists of 54 items, be used in analysis, that reflect more global
of which 1 to 9 are dichotomous, items 10 to aspects of quality of life and those are:
37 have Likert type answers of four points, – Global Deterioration of Quality of
while items 52,53 and 54 answered on a sca- Life: It is the sum of the following subscales:
le of seven points. This questionnaire is made Functional Status, Physical Symptoms,
out of the following subscales: Psychological Distress, Family and Social
– Functional Status: This subscale Problems, Sexual Problems, Satisfaction
refers to the level of loss of independence in with Medical Care. Having included the
everyday activities and self-care. A higher reversal of subscale scores where needed, a
score on this subscale indicates functional high score on this subscale indicates a
impairment. greater global impairment of quality of life.
– Physical Symptoms: This subscale – Global Perception of Quality of life:
measures the physical symptoms that the It is the sum of the variables: Subjective Per-
woman suffers as a consequence of her illness ception of Psychological State, Subjective
and the treatment she is receiving. A high Perception of Physical State, and Subjecti-
score in this subscale indicates graver physi- ve Perception of Quality of Life.
cal symptoms.
– Psychological Distress: It refers to the
RESULTS
level of psychological distress of the patient
in the week before filling out the question- Body Image, Sociodemographic and
naire. Medical Variables, and Social Support
– Family and Social Problems: This
subscale measures the repercussions her ill- To study the influence of the sociode-
ness and treatment have had on the patient’s mographic variables, the type of surgery,
social life in the last week. It includes an and the social support received on body
item that refers to the possible impact her image, a series of two-way analyses of
illness has had on her financial situation in variance (ANOVA) were conducted. In
the last week. The higher the score on this examining Age and Marital Status in rela-
scale, the worse the problems the subject tion to Body Image, it was found that Mari-
had to face. tal Status had a main effect F (1,47) =
– Sexual Problems: It refers to sexual 6,052, p< .05, while neither age FBody image in relation to self-esteem 109
Table 1. Means and Standard Deviations for Body Image
Body Image
Mean Standard Deviation F
Marital Status 1(not married) 31,70 6,15
2 (married) 38,53 6,94 6,052*
Age 1 (28-42) 37,00 7,45
2 (43-55) 37,71 7,59
3 (56-68) 36,00 6,57 0,781
Social Support enough 36,78 7,68
a lot 37,34 7,27 0,980
Type of Surgery lumpectomy 40,74 4,65
mastectomy 33,62 7,77 10,831*
Employment yes 37,19 6,79
no 37,30 7,82 0,015
Educational Level elementary 38,15 7,12
high-school 30,75 9,29
university 36,11 6,09 1,449
Has Children yes 37,78 7,38
no 33,71 5,65 0,03
Lives Alone yes 32,20 5,63
no 37,77 7,26 0,771
* p< 0,05
had a more positive body image than sub- significant tendency was observed related
jects that were single, divorced or wido- to body image, F (1, 49) = 3,953, p < .08.
wed. As for age, the results show that the The women that did not live alone
women in all three age groups had a com- scored higher on the body image scale
parable perception of their body image, than the women that did live alone.
without significant differences because of Finally, the impact of Type of Surgery on
their age. the patient’s Body Image was examined.
The influence of Age on Body Image The analysis of variance showed a signifi-
was also examined in combination with the cant main effect, F(1,49) = 10,831, p110 Dimitra Manos et al.
Table 2. Means and Standard Deviations for Self-Esteem
Self-Esteem
Mean Standard Deviation F
Marital Status 1(not married) 31,80 4,96
2 (married) 33,19 3,72 0,823
Age 1 (28-42) 28,88 4,88
2 (43-55) 34,00 3,28
3 (56-68) 32,55 3,53 5,516*
Social Support enough 32,44 4,03
a lot 33,02 3,99 0,216
Type of Surgery lumpectomy 33,15 4,60
mastectomy 32,69 3,26 0,06
Employment yes 32,23 4,13
no 33,59 3,75 0,782
Educational Level elementary 33,15 3,50
high-school 32,75 3,50
university 32,00 6,04 0,188
Has Children yes 33,02 3,70
no 32,29 5,77 0,123
Lives Alone yes 32,40 6,47
no 32,98 3,72 0,014
* p< 0,05
gical Distress, r = - .349, p< .05. The more Body Image and Self-Esteem
impaired was the patient’s quality of life, or
the greater her physical or psychological Body image was also examined in rela-
tion to self-esteem. First of all, Body Image
malaise, the worse her body image and vice
was significantly correlated with Self-
versa. Also, there was a significant tendency
Esteem, r = .321, p< .05. We were interes-
observed fro the relationship between Body ted in exploring whether the factors influen-
Image and the subscale for Functional Sta- cing body-image were the same as the ones
tus, r = - .264, p< .08, indicating that to a influencing self-esteem. To that end, a series
greater functional impairment correspon- of two-way ANOVAs were conducted,
ded a more negative body image. following he same method as before.
In addition, Body Image was signifi- It was shown that Age had a significant
cantly correlated with two of the subjective main effect in relation to Self-Esteem,
subscales: Subjective Perception of Quality F(2,47) = 5.516, pBody image in relation to self-esteem 111
Table 3. Correlations between Quality of Life subscales and Body Image
and Self-Esteem
Body Image Self-Esteem
Functional Status -,264 -,218
Physical Symptoms -,332* -,197
Psychological Distress -,349* -,246
Family and Social Problems -,186 -,110
Sexual Problems ,176 -,133
Satisfaction with Medical Care -,206 -,113
Global Deterioration of Quality of Life -,287* -,296*
Subjective Perception of Quality of Life ,373** ,289
Subjective Perception of Psychological State ,201 ,297*
Subjective Perception of Physical State ,291* -,012
Global Perception of Quality of Life ,299* ,343*
* p< 0,05 (two-tailed)
** p< 0,01 (two-tailed)
effect of the interaction of the variables Age DISCUSSION
and Marital Status.
For the variables Employment, Educa- The goal of this study was to explore
body image in women treated for breast can-
tional Level, Children, Lives Alone, amount
cer, in relation to certain sociodemographic
of Support received, and Type of Surgery,
variables, the type of surgery received, the
the analyses of variance yielded no signifi- amount of social support they felt they had,
cant effect in relation to Self-Esteem. and to their quality of life. Also, we wanted
When the relationship between self- to examine any possible relationships among
esteem and quality of life was examined the concepts of body image and self-esteem.
(Table 3) it was found that Self-Esteem corre- As far as the sociodemographic factors
lated negatively with Global Deterioration are concerned, we found that marital status
of Quality of Life, r = .296, p< .05. The grea- was related significantly with body image,
ter the deterioration of the quality of life, the with married women having a more positi-
lower the woman’s self-esteem was, and ve body image than women that were sin-
vice versa. Also, Self-Esteem correlated sig- gle, divorced or widowed. At the same time
nificantly with the Subjective Deterioration no significant relationship was found bet-
ween the age of the patient and her body
of Quality of Life, r = .289, p112 Dimitra Manos et al.
It is possible, as it was mentioned in the breast cancer. It was found that women that
introduction, that the effects attributed to age undergo a lumpectomy have a more positi-
by other authors, are more likely due to mari- ve body image than those that have under-
tal status, a hypothesis supported by Glyhos- gone a mastectomy. This result goes
ki et al(35) and possibly by our own results. It along with the findings of several other stu-
could be supported that women in the dies(20, 27-29) that have also shown the impor-
middle age group (43-55 years old) have a tance of opting for a less mutilating type of sur-
higher probability of being married rather gery, since it contributes to a better adjustment
than single, as could be the case with the of the patient in terms of her body image.
younger age group (28-42 years old). Also, the A third finding was the correlation bet-
patients in the middle age group have a higher ween the global impairment of the quality
probability of being married rather than divor- of life of the patient with breast cancer and
ced or widowed than the older age group (56- her body image. More specifically, it seems
68 years old). Thus, if the patients in the that the most significant aspects of the qua-
middle age group are found to have a better lity of life in that respect were the physical
body image, it is not clear if this is an effect of symptoms she has and her level of psycho-
age, marital status, or an interaction of both. logical distress, as well as the subjective
In the present analysis, the interaction of the perception the woman has of her quality of
two variables was examined and it resulted life and her physical condition. The woman
not significant, whereas marital status did that feels a great physical or psychological
have a significant effect on body image. malaise, also has a negative body image.
On the other hand, it is important to The same happens when the woman percei-
note that, whereas age did not have a signi- ves an impairment in her quality of life or
ficant effect on body image, it did have an her physical condition.
effect on self-esteem. As in much previous At the same time there was no relations-
research the dimensions of body image and hip found between sexual problems –as an
self-esteem are not always well distingui- aspect of quality of life-and the patient’s
shed, it is also possible that the discrepancy body image as was the case has been in pre-
between the present results and those of vious research(22,28,39). We might have failed
other studies is due to a different definition to find a relationship between body image
of the variables. and sexuality because of the time chosen to
Finally, following a suggestion made by evaluate these two variables. The assess-
Ghizzani et al(40) who found that in older ment was done 10 to 15 days after surgery
women the repercussions of breast cancer when –probably – most patients had not
and its treatment on body image depends on gone back to their normal sexual life or
the amount of support they received, the hadn’t even had yet any sexual contact.
effect of the interaction between age and Consequently, the questionnaire items
amount of support was examined. There addressing this facet of their quality of life
was no significant effect found for either of were irrelevant and as such incapable of
the variables or their interaction. The body detecting any possible sexual problems.
image of patients did not depend on their The other part of this study focused on
age or the amount of support they received the analysis of the relationship between
due to their illness. Body image was also body image and self-esteem. Self-image is
found to be independent of educational understood here as the cognitive component
level, of whether the woman is employed of one’s self-concept, that is to say one’s
outside the home, and of whether she lives beliefs on one’s self. Self esteem is conside-
alone or has children. red to be the affective component, the self-
The second important finding of our evaluations of who one is. Although body
analysis was that the type of surgery recei- image is but a part of one’s self-image, it is
ved affects the body image of women with the dimension most often examined in theBody image in relation to self-esteem 113
majority of the research studies. In this case, The results also showed that body ima-
the subjects were women diagnosed with ge was correlated to the patient’s subjecti-
and treated for breast cancer and the physi- ve perception of her physical condition,
cal aspect was the crucial component of self- while self-esteem was correlated to the
image, the one that would most probably be patient’s subjective perception of her
affected by this condition. So, it is body ima- psychological state. This finding confirms
ge that is considered here as the cognitive the understanding of body image as a cog-
part of self-concept, while self-esteem repre- nitive construct that reflects one’s corpo-
sents the emotional component. ral-physical reality, and as a consequence,
As expected, the two dimensions were to a more positive perception of one’s body
found to correlate significantly. When one corresponds a better body image. One the
dimension was affected, the same happe- other hand, self-esteem is confirmed as an
ned with the other. Yet, more specifically, emotional construct that represents the
the analysis of variance showed that the fac- psychological-emotional evaluation of the
tors influencing the woman’s body image, previous perception, and it changes in
were different from the factors influencing relation to the perception of one’s psycho-
her self-esteem. Body image was related to logical state. Higher self-esteem corres-
marital status and type of surgery. Self-esteem ponds to a positive perception of one’s
did not depend on these two factors, but it psychological condition. These findings
was influenced by the patient’s age. These agree with the theoretical model that con-
results might indicate that body image is siders self-image as a cognitive component
more susceptible to situational or transitory and self-esteem as an emotional compo-
factors than self-esteem which seems like a nent of the self-concept(9).
more stable part of the self, although it One of the limitations in the research
appears to develop with age. This conclu- aimed to examine body image is that there
sion follows the theoretical suggestions of is no integrative theoretical model that
various other authors, such as Anderson(55). includes all the variety and richness of the
Examining the relationship of body ima- concepts related to body image, self-esteem
ge and self-esteem with the quality of life, or self-concept. This lack of theoretical con-
we found that they both correlated negati- tinuity impedes the comparison and coordi-
vely with the global impairment of the qua- nation of the various investigative projects,
lity of life. In other words, when there was and it requires the definition of the concepts
impairment in the quality of life, both body used by each individual author.
image and self esteem were negative. Never- The data in the present study have con-
theless, in relationship to specific aspects of firmed the importance of various factors,
quality of life, body image correlated nega- such as marital status, type of surgery, and
tively with the Physical Symptoms subscale quality of life, in relation to body image in
and the Psychological Distress subscale, women with breast cancer. It was shown
whereas self-esteem only correlated to subs- that married women accept more and view
cales of the quality of life instrument that their bodies better than the women who are
measure subjective perceptions. So, body not married. It was confirmed once more
image is related to the presence of physical that women that have a lumpectomy ins-
symptoms and psychological distress, being tead of a mastectomy have a more positive
more negative when those are higher, whe- body image. The possible impairment of
reas it is not clear which aspect specifically the quality of life associated with the diag-
is related to changes in self-esteem. This nosis and treatment of breast cancer also
difference could also be used to support the resulted significant in relation to body ima-
claim made earlier that body image seems ge. The more the patient’s quality of life is
to be more sensitive to varying conditions affected, the worse her body image and the
than self-esteem. other way around. Finally, based on our fin-114 Dimitra Manos et al.
dings, it was shown that body image and 14. Dudas S. Manifestations of cancer and can-
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self-concept, depend on different factors lity. Cancer Nursing: Principles and Practice,
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highly related, but at times independent quency and correlates of posttraumatic-
from each other. stress-disorder-like symptoms after treat-
ment from breast cancer. J Consul Clin
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