APOS PSYCHOSOCIAL
POCKET GUIDE

All cancer survivors undergo a process of body image adaptation as the disease and its treatment will alter the body and its functioning in some way. Body image experiences are inherently subjective. As such, a patient’s body image experiences must be understood through the way they describe and perceive their own bodies. There can be a disconnect between the way the patient perceives his or her own body image and the way a healthcare provider or loved one sees the patient. For many survivors, body image changes that they experience – whether this involves changes to physical appearance or some aspect of the way the body functions (or both) – are a source of distress and discomfort. Patients who have difficulties coping with any type of body image change are likely to benefit from psychosocial care that addresses this important aspect of their well-being.

Characteristics of Body Image Changes Due to Cancer/Cancer Treatment:

• May have gradual vs. acute onset (e.g., post surgery)
• Can be temporary vs. permanent or long-lasting
• May be noticeable to others vs. hidden/invisible

Types of Body Image Concerns

• Scarring/disfigurement, swelling, skin discoloration
• Sensory changes (e.g., numbness, tingling, pain)
• Fatigue
• Sexual dysfunction
• Weight changes
• Use of prosthetics
• functional impairment (e.g., related to hearing, vision, speech, swallowing, gait, bowel/bladder).

SCREENING

Comprehensive cancer assessment typically involves screening for body image concerns during the disease course. The Three C’s approach (Common, Concerns, Consequences) is recommended as a framework for how all oncology healthcare professionals can approach conversations about body image during a clinical encounter¹.

Three C’s approach (Common, Concerns, Consequences)

• Inform patients that body image difficulties are very commonas a result of cancer and its treatment.
• Inquire about any specific concernsthe patient is having about changes to appearance or body functioning. Open-ended questions, empathic and reflective listening are to be used at this stage.
• Explore consequencesthat body image issues are having in the patient’s daily life, including areas of social, emotional and occupational functioning.
• Provide reassurance and psychoeducation to help manage expectations surrounding body image outcomes only after the 3 C’s have been explored.
• Further information on communication strategies related to body image care can be found elsewhere. ^{2, 3}

EVALUATION AND DIAGNOSIS

Body image within the oncology setting has been identified to exist on a continuum¹ with most patients experiencing normative or average body image concerns during cancer survivorship. Some may experience extreme concerns where body image significantly interferes with their daily lives.

Most importantly, body image experiences are not static, and can change over time and throughout the course of the cancer treatment trajectory. As such, providers must remain vigilant and continually assess the impact of treatment on a patient’s body image

Table 1 provides suggestions for fundamental elements of conducting a more thorough clinical assessment of body image concerns⁴. This assessment strategy is based on obtaining an understanding of the patient’s perception and description of the manner in which body image changes are affecting his or her daily functioning.

Click here to view table as PDF

TREATMENT

Patients with extreme body image concerns are likely to benefit from intensive therapy delivered by a mental health specialist to address:

• preoccupation with intrusive thoughts about body image discomfort
• high levels of social isolation or avoidance due to body image issues
• clinical levels of depression or anxiety due to body image distress
• managing unrealistic expectation for cosmetic and/or functional outcomes related to cancer treatment

Patients with mild to moderate body image distress may need brief supportive therapeutic interventions. These patients are likely to have more realistic and flexible expectations for their treatment outcomes but experience difficulties with coping.

There are an array of empirically supported body image interventions which can be utilized in the oncology setting drawn from cognitive-behavioral treatment strategies, motivational interviewing, and acceptance and commitment therapy.⁵  Such interventions can be used to help at different time points in the cancer treatment trajectory to help:

• facilitate treatment decisions related to body image
• cope with recent body image changes
• promote long term body image acceptance for patients with ongoing body image concerns.

At all time points, normalizing and validating body image concerns remains critical.

When facilitating treatment decisions related to body image, it is recommended that clinicians focus on promoting autonomy/choice, engage in goals/values clarification with the patient and concentrate heavily on helping the patient set realistic and flexible expectation for cosmetic and functional outcomes. It is vital to create a safe space where patients can explore their treatment options and facilitate communication with members of the treatment team.  Among the treatment strategies used to help patients cope with recent body image changes can include gradual exposure/systematic desensitization to mirror viewing as well as problem solving interventions and communication skills training.  Mind/body relaxation can be particularly useful as well as ongoing psychoeducation to manage expectations about treatment outcomes. Exploring and challenging patient’s appearance-related beliefs and assumptions are a core aspect of body image interventions. Strategies to promote long-term body image acceptance include cognitive restructuring and behavioral activation (particularly for those engaging in social isolation due to body image distress). Body esteem activities can also be used to improve body image acceptance over time which include planning appearance enhancing, sensory pleasing and health/fitness activities. Ultimately, it is helpful to on promoting greater cognitive flexibility surrounding body image thoughts and behaviors.

CULTURAL CONSIDERATIONS

Unfortunately, there is a paucity of literature addressing cultural considerations for body image assessment and treatment in the oncology setting. Within the broader body image field, the influence of Western beauty ideals for women is recognized to play a prominent role in the formation of a negative body image. There are no guidelines for working with oncology patients from varied cultural backgrounds to address body image concerns. However, it is always best practice to remain vigilant and attentive to the importance and meaning a patient attributes to affected body part(s) and the narrative he or she conveys about how resulting body image concerns relate to their cultural values and ideals.

CONCLUSION

Body image is an important psychosocial issue for cancer survivors that must be addressed as part of comprehensive cancer care. Body image concerns need to be normalized and validated in order for patients to feel comfortable discussing them with their healthcare team. Assessment and treatment strategies ranging from brief to more intensive are available to facilitate body image adaptation and can substantially enhance quality of life for patients and satisfaction with treatment outcomes.

References:

1. Fingeret MC, Body Image and Disfigurement. In: MD Anderson Manual of Psychosocial Oncology. Ed(s) J Duffy, A Valentine, McGraw-Hill; Columbus OH 271-288, 2010
2. Fingeret MC, Teo I, Epner DE. Managing Body Image Difficulties of Adult Cancer Patients: Lessons from Available Research. Cancer 120(5):633-641, 3/2014. PMCID: PMC4052456.
3. Fingeret MC, Teo, I (Eds) Body Image Care for Cancer Patients: Principles and Practices: New York, NY: Oxford University Press, 2018.
4. Annunziata, MA, Muzzatti B, Fingeret MC. Body Image Assessment in the Oncology Setting. Body Image Care for Cancer Patients: Principles and Practices, M.C. Fingeret and I. Teo (Eds), New York, NY: Oxford University Press, 35-55, 2018.
5. Espen MJ, Fingeret MC. Body Image: An Important Dimension in Cancer Care. In Psycho-Oncology (4^thEdition). W. Breitbart, P Butow, P Jacobsen, W Lam, M Lazenby, M Loscalzo (Eds). New York: Oxford University Press, 303-312, 2021