Body image is a concept cited extensively in the literature.1-11 It may be defined as a multifactorial mental construct, dynamically reshaped throughout life, and rooted both in the biologic and psychologic domain.12 Neurobiologic/somatic, psychologic/ affective, and context-related factors contribute to perceptions of body image across the life span.
Body image is a critical dimension of sexual identity.8,12 Body image may modulate sexual function and response through the complex physical and emotional interactions during sexual activity, and may be modified in turn by the quality of past and current sexual experiences.8,12 The sexual relationship is the most intimate of the interpersonal factors that contribute to body image perception and, specifically, to the erotic meaning of the breast in adulthood.
Breast cancer affects 8-10% of women in their lifetime; 25% are premenopausal when diagnosed.13 The beauty and appearance of the breast are important for a woman’s sense of femininity, body image, self-esteem, self-confidence, and eroticism.1-5,8,12 Female sexual identity, sexual function, and the sexual relationship may be adversely affected by the many changes and challenges facing the woman when diagnosis and treatment of breast cancer disrupts her life and that of her family.1-11 These changes are often accompanied by changes in body image that are brought about by psychologic and iatrogenic factors.
This chapter will discuss the impact of breast cancer on women’s sexuality with respect to body image by: (1) describing biologic and psychosocial contributions; (2) reviewing the key literature on the impact of breast cancer on body image and sexuality in cancer patients; (3) focusing on factors and coping strategies that may improve body image of cancer survivors after treatment; and (4) considering the impact on body image of genetic screening and prophylactic mastectomy for women at high risk of breast cancer.
Body image contributors
Biologic and psychosocial factors that contribute to body image are summarized in Table 7.4.1.
In the biologic domain, body image is influenced by sensory information such as sight, touch, smell, sound, taste, and proprioception. This sensory information contributes to the body schema, a major contributor to body image that integrates the sensorimotor aspects of the woman’s body. Visceral and autonomic components of body image are less frequently considered, although they may contribute to mood, a sense of well-being, fatigue, illness, and the ultimate perception of body image.12
Table 7.4.1. Factors contributing to body image
From the psychosocial point of view, cognitive, affective, emotional, sexual, cosmetic, and social factors further interact with physical issues in modulating body image.12 The comprehensive emotional and unconscious perception of the body is a major contributor to the private body consciousness, a psychoanalytic concept of more complex body image factors (see Chapters 3.1- 3.4).
Body image and sexuality in breast cancer patients
Breast cancer diagnosis and treatment may modify the woman’s body image and sexuality through several modalities. Factors dependent upon the illness, the context, and the individual interact to contribute to the woman’s body image and sexual outcome.8 Major illness-dependent and iatrogenic factors influencing body image and sexuality include stage of cancer, type of breast surgery, lymphedema, hair loss, iatrogenic premature menopause, and age at diagnosis (Table 7.4.2).
Stage of cancer
The stage of breast cancer affects body image, as it determines the extent of radical surgery; the need for lymph node removal; the presence and severity of lymphedema; the need for adjuvant chemotherapy, with the risk of iatrogenic premature menopause, and/or radiotherapy with consequent local and systemic symptoms; and the perception of the risk of death. In a study of 303 women with early stage breast cancer and 200 with advanced breast cancer, Kissane et al.9 found an overall prevalence of mood disorders, and depression and anxiety disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), of 45% and 42%, respectively, Women with advanced breast cancer were significantly less distressed by hair loss, but were more dissatisfied with body image and had higher rates of lymphedema and hot flushes, than the early-stage women. The rates of psychosocial distress were similarly high in both groups, although the illness-related causes of distress were different.
Table 7.4.2. Major factors affecting body image and sexuality in breast cancer survivors
1. Cancer related
• Age at diagnosis
• Type of cancer, stage and prognosis
• Conservative vs radical treatment
• Adjuvant chemotherapy and/or radiotherapy
• Treatment impact on ovarian function (sexual hormone production and infertility)
2. Woman dependent
• Life cycle stage and fulfillment of stage-related goals
• Coping strategies
• Pretreatment sexual experience, and its quality
• Premorbid personality and psychiatric status
3. Context dependent
• Family dynamics and couple dynamics and marital status
• Support network (friends, colleagues, relatives, self-help groups)
• Quality of relationship with health-care providers
Depression is significantly associated with lower sexual desire and arousal difficulties1-8 (see Chapter 16.2). Women with higher depression scores report more cancer-related distress pertaining to body image, fear of recurrence, posttraumatic stress disorder, and sexual problems. Those with longterm medical sequelae, such as lymphedema, have poorer adjustment than those who do not.14
The visual and tactile sensations and perceptions of the breast are affected differently according to the type of breast surgery performed.1-7 Important factors influencing sexual outcomes include lumpectomy versus mastectomy, immediate or delayed reconstruction of the breast, the need for adjuvant radiotherapy or chemotherapy, and presence and severity of side effects.
In a recent prospective study of 990 breast cancer patients followed for 5 years,11 mastectomy patients had significantly poorer body image and lower role and sexual function scores than patients undergoing breast-conserving therapy. Body image, sexual function and lifestyle disruptions did not improve over time.11 Accordingly, breast-conserving therapy, when oncologically appropriate, should be encouraged for patients in all age groups. However, conservative treatment does not guarantee a more positive physical outcome. A cross-sectional study of women 1 year after treatment suggested that, because of the need for adjuvant therapies, women treated by breast conservation have better body image but poorer physical function, particularly younger patients.15 Negative physical and sexual symptoms may be secondary to the premature iatrogenic menopause and/or to local sensory side effects of radiotherapy.
Except for breast carcinoma recurrence, no event is more dreaded than the development of lymphedema.16-18 The surgical removal of axillary nodes may impair lymphatic drainage from the arm. As a result, the arm becomes swollen, causing pain, progressive fibrosis, sensory distortion, discomfort, and disabi- lity18 “Arm problems” are cited by 26-72% of breast cancer patients.5,6 Fibrosis and lymphedema in the connective tissue and the muscular and functional impairment of the affected arms and fingers deeply affect the physical and psychologic dimensions of body image. When severe, it may impair body image even more than breast surgery. The clinician who, focusing on the risk of carcinoma recurrence, trivializes the nonlethal nature of lymphedema18 and may hinder adjustment to these symptoms. While the mastectomy can be hidden easily in social contexts, the disfigured arm/hand is a constant reminder of the breast cancer18 and may contribute to sexual difficulties.
Although limited to the period of chemotherapy, hair loss may be perceived as a major insult to body image, particularly in younger patients. Vulnerability to hair loss-related distress decreases with the progression of the disease.8,9
Iatrogenic premature menopause
Chemotherapy may cause ovarian failure and associated autonomic disturbances. Hot flushes, night sweats, night tachycardia, insomnia, arthralgia, mood changes, and general body shape changes associated with iatrogenic premature menopause may further alter body image. The effects of menopause on sexuality (see Chapter 9.2) are even more complex if the onset is premature19,20 (see Chapters 13.1-13.3).
Age moderates body image in breast cancer patients and survivors irrespective of illness- and treatment-related factors. Women diagnosed with breast cancer at a younger age often have sexual and psychosocial concerns that are less common among older women. A cross-sectional survey of 204 women diagnosed during the past 3.5 years with breast cancer at age 50 or younger indicated that: (a) mastectomy was associated with poorer body image and lower interest in sex; (b) chemotherapy was associated with greater sexual dysfunction; (c) sexual function (e.g., lubrication, sexual pain) was a greater problem than lack of sexual interest; (d) concerns about premature menopause and fertility were rated as the most problematic issues facing this group10 (see Chapter 7.1).
While the ramifications of age on body image among breast cancer patients vary by individual and by reproductive goals,8,21-25 this does not mean that elderly women are less vulnerable to issues of body image from breast surgery. In Engel’s 5-year prospective study, body image, sexual function, and lifestyle disruption scores did not improve over time, indicating that sexual vulnerability persists or increases over time.11 This finding was substantiated in the prospective study by Ganz et al.4
Ultimately, the woman judges her body image by integrating the visible results of surgery, the personal and cultural context of oncologic breast surgery, and the threat of death. An especially sensitive issue is the decision regarding whether or not to perform breast reconstruction at the time of the mastectomy. Attitudes of physicians toward conservative (in younger patients) or radical treatment (in older patients) may influence the patient’s decision, with possible regrets later.26
A feeling of helplessness, hopelessness, or resignation is reported to be significantly associated with depression and vulnerability to body image impairments.9,26-28 Cognitive deficits secondary to chemotherapy seem to be independent of depression and anxiety and independent of menopausal status.28
Affective factors seem to change the vulnerability of body image. Love is one of the most powerful shapers of body image, able to lessen the impact of major physical impairments and changes. An increase in affection and intimacy reduces the negative impact of cancer surgery on body image and sexual satisfaction. At the opposite end, frustration with love and need for attachment can impair body image perception even in healthy people with no alterations in physical appearance. After breast cancer, the women most vulnerable to poor body image are younger and either single or in troubled relation-ships.1,2,10
Mood, anxiety, and positive or negative emotions shape the inner perception of body image. Depression and anxiety, whether pre-existent or triggered by the cancer diagnosis and treatment, and made worse in the case of premature iatrogenic menopause, may lead to a poorer body image outcome. Depression and anxiety may affect body image and sexual function via nonhormonal pathways, as reported in an average of 17-25% of breast cancer patients, and may specifically contribute to the loss of libido.27
The primary variable affecting cosmetic outcome of breast cancer surgery is surgical skill,11 while taking into account the oncologic need for radical surgery. However, cosmetic results of surgery may be enhanced by maintaining the integrity of pleasurable sensations from the nipple and the skin, or may be impaired by loss of sensations or unwanted sensations (paresthesia, “pins and needles,” etc.).4,5,8
Breast cancer may dramatically impair sexuality for the woman and the couple, from both the biologic and psychosexual points of view. Sexual identity may be harmed,8 becoming more vulnerable with more radical surgery,1,2,4,6,7 lymphedema,8,16-18 premature iatrogenic menopause,24 and chemotherapy-induced hair loss. The women most vulnerable to these effects are single, younger, in troubled relationships, have lower income, and have poor overall social support.1,2,10
Sexual function may be impaired as well. Sexual desire and mental arousal are diminished in a significant percentage of breast cancer patients1-8 (see Chapters 6.1-6.5). The breast is a major sign of femininity. Breast foreplay may stimulate and trigger sexual arousal, desire, and even orgasm. The pleasure felt from breast kissing and caressing contributes to the erotic meaning of this part of the body. After breast surgery, many women report impaired, distorted, or unpleasant physical sensations. A total of 44% of women with partial mastectomy and 83% of those with breast reconstruction report that pleasure from breast caresses had decreased.1 Loss of breast sensitivity may contribute to further loss of sexual desire and of mental and peripheral nongenital arousal.8 Uneasiness at being naked increases the tendency to keep the breast covered while making love, and to avoid any further breast stimulation.
Vaginal dryness and dyspareunia are identified as problems by 35-60% of normal, postmenopausal women due to lack of estrogen20 (see Chapter 7.2). Pre-existing arousal disorders may be made worse by the menopausal loss of estrogen and loss of libido after breast cancer. A second biologic cause of arousal difficulties is the spasm of the pubococcygeal muscle secondary to vaginal dryness and dyspareunia.8 Attention to hypertonic conditions of the pelvic floor secondary to dyspareunia is important in breast cancer patients. Teaching relaxation of the levator ani muscle and encouraging self-massage with a medicated oil may effectively relieve dyspareunia and arousal disorders secondary to hypoestrogenism, when the woman is unable to receive estrogen treatment because of the risk of breast cancer recurrence.8,29 Controversy still exists regarding the use of hormonal therapy after breast cancer. Topical vaginal estrogen treatments are considered safe by many oncologists; however, the decision must be made with the patient being informed of the risks and benefits. Patients with good libido and genital arousal disorders may have some clinical improvement with vasoactive drugs, such as selective phosphodiesterase type-5 inhibitors,30 that are not contraindicated in breast cancer patients. Considering the high prevalence of dyspareunia in breast cancer patients, the viability of nonhormonal alternative treatments needs to be evaluated.
Quality-of-life impairment secondary to iatrogenic factors and/or menopause may harm the woman’s sense of eroticism.10-13 In a prospective, longitudinal study conducted by Ganz et al.,5 61% of breast cancer patients reported difficulty with sexual arousal and 57% reported difficulty with lubrication. Interestingly, the group attained maximum recovery from the physical and psychologic trauma of cancer treatment within 1 year of surgery. A number of aspects of quality of life, including sexuality, significantly worsened after that time. Another study reported that women who received chemotherapy tended to have less frequent desire, more vaginal dryness, more dyspareu- nia, less frequent sex, and reduced ability to reach orgasm through intercourse; overall, sexual satisfaction was significantly decreased.1 Postmenopausal breast cancer survivors were more likely to report vaginal dryness and tightness, as well as genital pain, with sexual activity.1 Loss of ovarian androgens secondary to chemotherapy may contribute to loss of libido.20,28
Orgasmic difficulties may be the end point of a number of biologic as well as motivational-affective and cognitive factors (see Chapter 6.4). Difficulty in reaching orgasm was reported in 55% of patients in the study by Ganz et al.,5 with a significant decrease in sexual function over the 3-year follow-up. In a retrospective study by Schover et al.,1 the ability to reach orgasm through intercourse tended to be significantly reduced in women who received chemotherapy, although their ability to reach orgasm through noncoital caressing did not differ from control women. The inhibitory effect of dyspareunia on vaginal orgasm might explain this difference, together with the effect of androgen-dependent nitric oxide pathways on clitoral response, and estrogen-dependent vasoactive intestinal peptide on vaginal response.31,32
Sexual satisfaction, which includes both physical and emotional aspects, should be investigated separately. Pain and disappointing sexual experiences might be responsible for the significantly reduced satisfaction reported by breast cancer survivors.2 A prospective study indicated that sexual satisfaction remained significantly reduced in breast cancer survivors (compared to age-matched controls) 8 years after primary treatment.6 Objective parameters to quantify and qualify sexual satisfaction are at present undefined. The diagnosis of cancer places a strain on both the couple and the family.1,2,9,33 Young women and young couples may be particularly vulnerable, as studies indicate that younger women experience more emotional distress than older women, and younger husbands report more difficulty in fulfilling domestic roles and feel more vulnerable to life stresses.34 When breast cancer is diagnosed, the demands of the illness supersede the normal demands of family life, and the impact on the family may vary depending on the phase of the family life cycle at the time of cancer diagnosis.34
Social factors may be divided into two major categories: the “social mirror”, which is determined by the culturally based importance of the breast and its aesthetics; and the “social network”, which encompasses the woman’s resources for support. Health-care providers and self-help groups may represent an important resource for body image concerns. However, one study reported that 62% of breast cancer patients found it easier to discuss their sexual problems during their illness with their partner than with physicians and psychologists, and only 15% of breast cancer patients openly expressed their concerns to health-care professionals.35
Coping strategies to improve body image after breast cancer
Family and psychologic support, self-help groups, and good relationships between the patient and her health-care providers may all contribute to reducing the distress associated with the diagnosis and treatment of breast cancer. Regular exercise is an effective coping strategy that deserves special emphasis for its positive effects, its consistency over time, and its low cost.
Indeed, studies have shown that breast cancer survivors who exercise regularly, in comparison with sedentary women, have significantly more positive attitudes toward their physical condition and sexual attractiveness, as well as significantly less confusion, fatigue, depression, and mood disorder, regardless of age. The positive impact of regular exercise on body image, body schema, and self-image lessens the specific impact of breast changes. Due to the positive effects of exercise on mood, sexual desire may be less impaired and sexual arousal facilitated.
Psychosexual functioning after bilateral prophylactic mastectomy
Women with a strong family history of breast cancer, or a BCRA1 or BCRA2 mutation (markers of significantly higher vulnerability to developing breast cancer in their lifetime), are encouraged to undergo bilateral prophylactic mastectomy. Metcalfe et al.36 examined psychosocial outcomes related to this procedure. While the vast majority (97%) were satisfied with their decision to have the surgery, younger women (< 50 years) were less likely to report satisfaction than older women. Breast reconstruction was associated with higher levels of body satisfaction. Van Geel37 reported that prophylactic mastectomy decreased women’s anxiety about developing breast cancer but had a negative impact on their sexual lives. Appropriate sexual counseling should be offered to women at high risk of breast cancer before and after surgery to ease the impact of this distressing decision.
Breast cancer may have a strong effect on a woman’s body image and impair her sexual identity, sexual function, and sexual relationship. The impact of breast cancer on the sexuality of the individual woman is dependent upon the cancer, the woman, and the context. The issues of body image and sexuality after breast cancer become increasingly important with increasing time after surgery. The vulnerability of body image and sexuality is reduced in women with early-stage breast cancer who undergo conservative breast surgery, have limited side effects, enjoy a strong network of family and social support, and exercise regularly. The vulnerability of both body image and sexuality is higher in those who have advanced breast cancer, need adjuvant treatment, have lymphedema, are sedentary, have poor family and social support, and/or are single or in unstable relationships. The fact that overall adjustment and quality of life of breast cancer survivors are positive in an average of 70-80% of cases should not mask the fact that outcomes are frequently less favorable for body image, sexual function, and physical satisfaction.
Breast cancer survivors and their partners may need sexual counseling during and after cancer treatment. Psychologic counseling is available in most hospitals in North America and Europe. Unfortunately, the opportunity for sexual counseling is rarely offered by oncologic services. Competent sexual support could greatly improve the quality of intimacy, body image, and sexual relationships in cancer patients, cancer survivors, and their partners.
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