Perception of Self-esteem and Body Image among Women with Breast Cancer of a University Hospital in Tunisia

Full text

_____________________________________________________________________________________________________
*Corresponding author: E-mail: yasminebenrejeb@hotmail.com;
Journal of Advances in Medicine and Medical Research
23(4): 1-12, 2017; Article no.JAMMR.35567
ISSN: 2456-8899
(Past name: British Journal of Medicine and Medical Research, Past ISSN: 2231-0614,
NLM ID: 101570965)
Perception of Self-esteem and Body Image among
Women with Breast Cancer of a University Hospital
in Tunisia
Hela Ghali
1*
, Sirine Fendri
2
, Ines Ayedi
3
, Iheb Bougmiza
4
, Asma Ammar
1
,
Imtinene Belaid
5
, Njah Mansour
1
and Nabiha Bouafia
1
1
Department of Hospital Hygiene, University Hospital Farhat Hached, Sousse, Tunisia.
2
Superior Institute of Nursing, Sousse, Tunisia.
3
Department of Oncology, CHU Habib Bourguiba, Sfax, Tunisia.
4
Department of Preventive and Community Medicine, University of Medecine of Sousse, Tunisia.
5
Department of Oncology, University Hospital Farhat Hached, Sousse, Tunisia.
Authors’ contributions
This work was carried out in collaboration between all authors. Author HG designed the study,
performed the statistical analysis, wrote the protocol, and the first draft of the manuscript. Authors HG,
SF, IA, Iheb Bougmiza, AA, Imtinene Belaid, NM and NB managed the analyses of the study. Author
SF managed the literature searches. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/JAMMR/2017/35567
Editor(s):
(1) Dario Marchetti, Director, Biomarker Research Program, The Methodist Hospital Research Institute, USA and Professor,
Department of Pathology and Genomic Medicine, Visiting Professor, Department of Molecular & Cellular Biology, Baylor
College of Medicine, USA and Member, Methodist Cancer Center, Houston Methodist Hospital, Houston, USA.
(2)
Muhammad Torequl Islam, Nuclear of Pharmaceutical Technology (NTF), Federal University of Piaui, Brazil.
(3)
Philippe E. Spiess, Department of Genitourinary Oncology, Moffitt Cancer Center, USA and Department of Urology and
Department of Oncologic Sciences (Joint Appointment), College of Medicine, University of South Florida, Tampa, FL, USA.
Reviewers:
(1) Janani Kumar, University of North Dakota, USA.
(2)
José Carlos Souza, Mato Grosso do Sul State University, Brazil.
Complete Peer review History:
http://www.sciencedomain.org/review-history/20463
Received 19
th
July 2017
Accepted 5
th
August 2017
Published 10
th
August 2017
ABSTRACT
Background:
Breast cancer is a major public health problem. It represents the first female cancer
which creates physical, psychological and social disorders.
Objectives: This study aimed to describe the perception of the self-esteem and the body image of
women reached by breast cancer in the hospital of Habib Bourguiba of Sfax – Tunisia during three
months.
Methods: It is a cross-sectional observational study. Two measure scales of beforehand designed
and validated were administered to 125 patients treated for breast cancer: a scale estimating the
Original Research Article

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
2
body image according to Hopwood and a scale estimating the self-esteem according to
Rosenberg.
Results: 79% of the investigated women had weak self-esteem and 62% had a distress of the
body image. Our study also showed that there is a statistically significant correlation between the
perception of the body image and the self-esteem. The presence of history of psychiatric
pathologies (P=0,007) and alopecia (p=0,006) are statistically correlated to a body image distress.
Civil status (p=0,025) and alopecia (p=0,014) statistically impacted the perception of self-esteem.
Conclusion: In order to improve the quality of life of women with breast cancer, healthcare
professionals should take into consideration the psychological effect of the consequences of this
disease.
Keywords: Breast cancer; self-esteem; body-image; women.
1. INTRODUCTION
Breast cancer is the second most common
cancer in the world and, by far the most frequent
cancer among women with an estimated 1.67
million new cancer cases diagnosed in 2012 [1].
Western literature reports various incidences of
breast cancer among women under 35 years old,
which may reach 4% [2].
Breast cancer is also the most common cancer
among women in Tunisia. The incidence of this
disease is close to 30 new cases per 100 000
women per year. It is estimated that it will affect
one in 27 women during their lifetime. Besides, it
is often diagnosed at a late stage with an
important tumor size [3].
Diagnosis and treatment of breast cancer affect
women physically and also cause emotional
stress. All sorts of treatments (surgery,
chemotherapy, radiation therapy, hormonal
therapy) could induce a change in their
appearance. These changes may be in short
term or long term [4].
Body image is defined commonly as a subjective
picture of an individual’s own physical
appearance established by self observation and
by noting the reactions of others [5]. However,
body image also includes an attitude of
satisfaction or dissatisfaction with one’s body that
varies according to two factors: Investment in
appearance, which concerns an individual’s view
on the importance of his or her appearance, and
self-evaluation, which relates to cultural ideals for
physical appearance and beauty and the
discrepancy between perceived body image and
these ideals [6].
Women who are treated for breast cancer are
exposed to marked changes in their physical
appearance, such as loss of part or both breasts,
scars from surgery, and skin changes related to
radiotherapy. Furthermore, systemic treatments
with chemotherapy or hormonal therapy often
lead to an increased body weight [7,8]. These
changes are related intimately to physical
appearance and body image.
Body image is linked closely to identity, self-
esteem, attractiveness, sexual functioning, and
social relationships [9].
Furthermore, the way one feels about oneself
crucially affects all aspects of the life
experiences. Self-esteem constitutes the key to
the success or failure of a person and to
understanding him/herself and others. It also
reflects the ability to cope with life’s challenges,
to respect and defend one’s own interests and
requirements [10]. Psychological research has
documented that body image problems are
associated with poor self-esteem, social anxiety,
self-consciousness, and depressive symptoms
[11].
In Tunisia, although breast cancer is the first
female cancer, studies on body image and self-
esteem among women with breast cancer have
not been published.
We aim to describe the perception of both self-
esteem and image of the body among women
with breast cancer at the department of Medical
Oncology at Habib Bourguiba University hospital
in Tunisia, and to determine the factors
associated with such perceptions.
2. METHODS
2.1 Population of the Study
This observational, cross-sectional, quantitative
study, was carried out at the Department of

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
3
Medical Oncology of the University Hospital
Habib Bourguiba, Sfax – Tunisia.
An active search for women who had breast
cancer presenting to the outpatient clinic during
three months period, from February 15
th
to May
17
th
, 2016 was performed.
All outpatients’ women whose breast cancer was
histologically confirmed who were under
treatment (chemotherapy, radiation therapy or
hormonal therapy), and who agreed to participate
in the study through understanding and
signing the consent form, were included in our
study. Women unable to respond (no-
cooperating, deaf…), and women hospitalized
at the department were excluded from this
study.
2.2 Conduct of the Study and Collection
of Data
The questionnaire was distributed and patients
responded by themselves. The investigator
interfered only at the request of the respondent
to explain some of the questions. Every woman
contacted was briefly made aware of the
objectives of the study while insisting on the
anonymity and confidentiality of data.
Three instruments were used for the data
collection. The first, constructed by the
researchers of this study, considered the
demographic and clinical data of the women
included in our study. The second, the
Rosenberg Scale [12] was applied to evaluate
the self-esteem. This is a self-administered scale
and consists of ten questions with the following
response options: strongly agree, agree,
disagree and strongly disagree. Furthermore, in
order to calculate the total score, we add the
values assigned to each item according to the
Likert scale. Given that the various items are not
formulated in the same direction, the calculation
of the score will be the sum of the values of the
items 1, 3, 4, 7 and 10 and the inverted values of
items 2, 5, 6, 8 and 9. The total score varies from
10 to 40. For the classification of self-esteem, all
the items are summed, which provides a single
value for the scale. According to the total,
perception of self-esteem can be rated as very
high (score greater than 39 points), high (score
between 34 and 39 points), average (score
between 31 and 34 points), low (score between
25 and 31 points), and very low (scores below 25
points). The greater the overall score, the higher
the self-esteem.
Subsequently, the Body Image Scale (BIS) is a
10-item, self-rating scale that was developed to
ascertain changes in the body image of cancer
patients [13]. Five BIS items concerned general
body image issues: feeling self-conscious,
dissatisfied when dressed, difficulty looking at
yourself naked, avoid others because of
appearance, and dissatisfied with body. The
other 5 BIS items concerned body image in
relation to the cancer experience: less physically
attractive, less feminine, less sexually attractive,
body less whole, and dissatisfied with scar. The
answer to each item is done according to a 4-
point Likert scale respectively as follows: 0, not
at all; 1, a little; 2, quite a bit; and 3, very much.
Higher scores represent poorer body image. The
total score varies from 10 to 40. As well if the
score varies between 25 and 40, we talk about
poorer body image score. On the other hand if
the score is below 25, we talk about better body
image score.
For the needs of the study, a translation of both
scales was done by two sworn interpreters. One
has ensured the translation of the French version
to the Arabic version and the other from the
Arabic version to the French version. The audit of
the concordance of the items has been carried
out by a group of experts represented by a
gynaecologist, a psychologist, a psychiatrist, an
oncologist and an epidemiologist. Internal
consistencies were α= 0.94 for BIS and α=0.92
for the self-esteem scale, reflecting a good
internal consistency of the two measurement
instruments.
2.3 Statistical Analysis
The statistical analysis was performed using the
software "Microsoft Excel 2016" and the
Software Program Statistical Package for the
Social Sciences (SPSS) version 23. It included a
calculation of simple and relative frequencies
(percentages) for each of the qualitative
variables, and a calculation of the averages and
of the medians and standard deviations for
quantitative variables. In order to test statistically
crosses made between certain variables, we
used the test of χ
2
and the t test of Student for
the comparison of the averages.
The perceptions of the image of the body and the
self-esteem were expressed through the
calculation of overall scores.
Univariate analyses were performed to compare
women with better body image score versus

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
4
those with a poorer body image score according
to the different socio-demographic and clinical
variables, and to compare women having self-
esteem more than average versus those with a
low self-esteem. The level of significance was set
at P < 0.05. Finally, the correlation of "Pearson"
has been used to study the relationship between
the perception of the image of the body and that
of the self-esteem.
3. RESULTS
3.1 Sociodemographic Characteristics
(Table 1)
In total, 125 women have been included. The
mean age was 49.56±10.59 years, which varied
from 26 to 71 years. The majority (62.4%) were
in the age group 35-55 years. 67% of the women
were married. A primary level education was
found in 52.8% of cases. Our patients were
housewives in 67.2% of cases. 46% of
participants had an average socio-economic
level. Almost half of the women (57%) were of
urban origin.
3.2 Medical History (Table 1)
The history of breastfeeding has been found in
66% of patients. The family history of breast
cancer has been noted in 55 patients, which was
in 53% of cases among first-degree relatives
(aunt, cousin...). A history of psychiatric
pathologies was noted in 12% of the women,
among which, the depression was present in
80% of cases.
3.3 Clinical Characteristics (Table 2)
Mean time to first consultation was 56.37 ± 49.03
months. 96% of the patients had undergone
surgery. Most of the women underwent unilateral
radical surgery (90%). For the 30% of women
who underwent a conservative treatment, the
aspect of the remaining breast was not
satisfactory in 72% of cases. 99.2% of the
women underwent adjuvant chemotherapy,
72.8% received radiation therapy, and 49.6%
hormonal therapy. Most frequent adverse effects
of chemotherapy were alopecia in 46.8% of
cases and nausea and/or vomiting in 48.4% of
cases.
Table 1. Sociodemographic and medical history characterization of our study group
Characteristics
Number (n)
Frequency (%)
Sociodemographic
Age group (in years)
(n=125) < 35 years 12 9.6
35 – 55 years 78 62.4
> 55 years 35 24
Marital status
(n=125) Married 84 67
Divorced 11 9
Single 16 13
Widow 14 11
Level of education
(n=125) University 7 5.6
Secondary 36 28.8
Primary 66 52.8
Never educated 16 12.8
Socioeconomic level
(n=125) Low 49 39
Moderate 58 46
High 18 15
Geographical origin
(n=125) Rural 54 43
Urban 71 57
Medical history
Breastfeeding
(n=125)
Yes 82 66
No 43 34
Family history of breast
cancer
(n=55; 44%)
First degree relatives 66 53
Other relatives 59 47
Psychiatric pathologies
(n=15; 12%) Depression 12 80
Hallucination 2 13
Acute stress 1 7

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
5
3.4 Perception of the Body Image
(Table 3)
The average score for body image perception
was 28.33±8.52. 62% had poor body image
(score between 25 and 40). More than the 1/3 of
the patients has responded "very much" on the
item 7" Did you avoid people because of the way
you felt about your appearance? "And on the
item 10 " Have you been dissatisfied with the
appearance of your scar(s)?".
3.5 Perception of the Self-esteem
(Table 4)
The average score for self-esteem perception
was of 23.59±8.19. 78.4% of the women had low
self-esteem (score < 31). 61% of the patients
responded "strongly disagree" on the item 7 "I
feel that I’m a person of worth, at least on an
equal plane with others". 44% responded
"disagree" for the item 3 " I feel that I have a
number of good qualities".
3.6 Factors Influencing the Perception of
the Body Image (Table 5)
3.6.1 Comparison between poorer and better
body image according to
sociodemographic and medical history
characteristics
The groups with poorer and better body image
did not differ significantly on demographic
variables. In fact, although in terms of relative
frequencies, it seems that poorer body image is
more frequent among single women aged less
than 55 years old, having secondary or university
level of schooling and those of urban origin, the
difference was not statistically significant.
Concerning medical history variables, a greater
proportion of women who had a poorer body
image had history of psychiatric pathologies
(18.2% versus 2.1% among better body image).
This difference was statistically significant
(p=0.007). However, no significant difference has
been revealed on family histories of breast
cancer and on the history of breastfeeding.
3.6.2 Comparison between poorer and better
body image according to clinical
characteristics
A greater proportion of women who had a better
body image had a longer mean time to first
consultation (66.15±47.65 months versus
50.27±49.20 months among those with poorer
body image) without indicating statistically
significant difference between the two groups (p=
0.077).
We have not noticed a statistically significant
difference between the two groups according to
the type of surgical treatment (p=0,871).
In addition, the non satisfaction about the
appearance of the remaining breast in case of
conservative surgery was observed in 55.6% of
the women with better body image versus 81% of
the other group. However, this difference was not
significant (p=0.159). Furthermore, while the
exposure to the hormonal therapy has no
effect on the perception of the image of the
body, we have found that poorer body image
was significantly more frequent in women
treated by radiotherapy compared to those
who have not been exposed to this type of
treatment. The comparison according to
exposure to chemotherapy was not possible
because only 1 patient did not receive
chemotherapy.
Table 2. Clinical characterization of women with breast cancer
Variables
Number (n)
Frequency (%)
Type of treatment
(n=125) Chemotherapy Yes 124 99.2
No 1 0.8
Radiotherapy Yes 91 72.8
No 34 27.2
Hormonal therapy Yes 62 49.6
No 63 50.4
Surgery Yes 120 96
No 5 4
Type of surgery (n=120) Conservative 36 30
Mastectomy 84 70
Side of mastectomy (n=84) Unilateral 75 90
Bilateral 9 10

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
6
Table 3. Response frequency for individual items of the body image scale
Item Not at
all (%) A little
(%) Quite a
bite (%) Very much
(%)
1.Have you been feeling self-conscious about
your appearance 9.2 24.8 26.4 37.6
2. Have you felt less physically attractive as a
result of your disease or treatment? 10.4 32 24 33.6
3. Have you been dissatisfied with your
appearance when dressed? 16 26.4 20.8 36.8
4. Have you been feeling less feminine as a
result of your disease or treatment? 19.2 23.2 24.8 32.8
5. Did you find it difficult to look at yourself
naked? 20 24.8 19.2 36
6. Have you been feeling less sexually attractive
as a result of your disease or treatment? 8.8 32 27.2 32
7. Did you avoid people because of the way you
felt about your appearance? 14.4 24 23.2 38.4
8. Have you been feeling the treatment has left
your body less whole? 8.8 31.2 24 36
9. Have you been dissatisfied with your body? 12 23.2 32 32.8
10. Have you been dissatisfied with the
appearance of your scar(s)? 9.4 20.8 29.6 40
Our study showed a significant difference
between the two groups according to the
existence of the alopecia as an adverse effect of
chemotherapy (p = 0.006). In fact, the frequency
of the alopecia is statistically higher among
women with poorer body image (56.6%)
than among those with better body image
(31.3%).
3.7 Factors Influencing the Perception of
Self-esteem (Table 6)
3.7.1 Comparison between low and more
than the average self-esteem according
to sociodemographic and medical
history characteristics
Among the socio-demographic characteristics
studied, the univariate analysis shows significant
difference only for the civil status. In fact, it is
clear that the presence of the partner was
significantly higher among women with a medium
or high self-esteem (85.2%) than among those
with a low self-esteem (62.2%) (p=0.025).
No significant difference was found between
women with a low self-esteem and the other
group according to the presence of the history of
psychiatric pathologies, family history of breast
cancer and a history of breast feeding.
3.7.2 Comparison between Low and More
than the average self-esteem according
to clinical characteristics
According to the average time elapsed since the
discovery of the disease, the comparison of the
perception of the self-esteem has shown a higher
time among women with a self-esteem more than
average (average duration= 70.04±47.43
months) than among those with a low self-
esteem (average duration = 52.60±49.04
months) without having indicated statistically
significant difference between the two groups (p=
0.102).
We have not noticed a statistically significant
difference between women with a self-esteem
more than average and women having a low self-
esteem depending on the type of surgical
treatment indicated (p=0.668).
In addition, the non satisfaction to the
appearance of the breast remaining in case of
conservative surgery was observed in 55.6%
women with a self-esteem more than average
against 77.8% of those with a low self-esteem
without being statistically significant (p=0.226).
In addition, exposure to the endocrine therapy
and to radiotherapy had no effect on the
perception of the self-esteem.

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
7
Table 4. Response frequency for individual items of the self-esteem scale
Item
Strongly
agree (%)
Agree
(%)
Disagree
(%)
Strongly
disagree
(%)
1. On the whole, I am satisfied with myself. 20.8 21.6 36.8 20.8
2. At times I think I am no good at all. 19.2 24.8 29.6 26.4
3. I feel that I have a number of good
qualities.
18.4 20 44 17.6
4. I am able to do things as well as most
other people. 19.2 19.2 36 25.6
5. I feel I do not have much to be proud of. 17.6 20 33.6 28.8
6. I certainly feel useless at times. 17.6 29.6 28.8 24
7. I feel that I'm a person of worth, at least on
an equal plane with others. 0 0 39.2 60.8
8. I wish I could have more respect for
myself. 15.2 25.6 32.8 26.4
9. All in all, I am inclined to feel that I am a
failure. 18.4 18.4 37.6 25.6
10. I take a positive attitude toward myself. 20.8 22.4 33.6 23.2
Table 5. Evaluation of the body image according to sociodemographic, medical history and
clinical characteristics
Characteristics
Better body
image (n=48)
(%)
Poorer body
image (n=77)
(%)
P
So
ciodemographic
Age group
< 35 years 3 (6.3) 9 (11.7)
NS 35 – 55 years 28 (58.3) 50 (64.9)
> 55 years 17 (35.4) 18 (23.4)
Marital status With partner 37 (77.1) 47 (61) NS
Without partner 11 (22.9) 30 (39)
Level of
education University+ Secondary 14 (29.2) 29 (37.7)
NS Never educated +Primary 34 (70.8) 48 (62.3)
Socioeconomic
level Low 26 (54.2) 50 (64.9)
NS Moderate+ High 22 (45.8) 27 (35.1)
Geographical
origin Rural 22 (45.8) 32 (41.6)
NS Urban 26 (54.2) 45 (58.4)
Medical histo
ry
Family history of
breast cancer Yes 23 (47.9) 32 (41.6)
NS No 25 (52.1) 45 (58.4)
Psychiatric
Pathologies Yes 1 (2.1) 14 (18.2)
0.007 No 47 (97.9) 63 (81.8)
Breastfeeding
Yes 34 (70.8) 48 (62.3)
NS No 14 (29.2) 29 (37.7)
Clinical data
Endocrine treatment Yes 26 (54.2) 36 (46.8)
NS No 22 (45.8) 41 (53.2)
Radiotherapy Yes 40 (83.3) 51 (66.2)
0.037 No 8 (16.7) 26 (33.8)
Better body
image (n=48)
Poorer body
image (n=72) P
Mastectomy 34 (70.8) 50 (69.4) NS
Conservative treatment 14 (29.2) 22 (30.6)
NS: No significant difference

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
8
Table 6. Evaluation of the self-esteem according to sociodemographic, medical history and
clinical characteristics
Characteristics
More than the
average self-
esteem (n=27) (%)
Low self
-
esteem
(n=98) (%)
P
Sociodemographic
Age group
< 35 years 3 (11.1) 9 (9.2)
NS
35
–
55 years
13 (48.2)
65 (66.3)
> 55 years 11 (40.7) 24 (24.5)
Marital status With partner 23 (85.2) 61 (62.2) 0.025
Without partner 4 (14.8) 37 (37.8)
Level of education University+ Secondary 23 (85.2) 61 (62.2)
NS Never educated +Primary 4 (14.8) 37 (37.8)
Socioeconomic
level Low 23 (85.2) 61 (62.2)
NS Moderate+ High 4 (14.8) 37 (37.8)
Geographical
origin Rural 23 (85.2) 61 (62.2)
NS Urban 4 (14.8) 37 (37.8)
Medical history
Family history of
breast cancer Yes 12 (44.4) 43 (43.9)
NS No 15 (55.6) 55 (56.1)
Psychiatric
Pathologies Yes 0 (0) 15 (15.3)
NS No 27 (100) 83 (84,7)
Breastfeeding
Yes 19 (70.4) 63 (64.3)
NS No 8 (29.6) 35 (35.7)
Clinical
data
Endocrine treatment Yes 14 (51.9) 48 (49)
NS No 13 (48.1) 50 (51)
Radiotherapy Yes 19 (70.4) 72 (73.5)
NS No 8 (29.6) 26 (26.5)
More than the
average self-
esteem (n=27)
Low self
-
esteem
(n=93) P
Mastectomy 18 (66.7) 66 (71) NS
Conservative treatment 9 (33.3) 27 (29)
NS: No significant difference
Our study showed a significant difference
between the two groups according to the
existence of the alopecia as an adverse effect of
chemotherapy (p = 0.014). In fact, the frequency
of the Alopecia is statistically higher among
women with a low self-esteem (52.6%) than
among those with self-esteem more than
average (25.9%).
3.8 Pearson’s Correlation between the
Perception of Self –esteem and Body
Image
Our study showed that there is a statistically
significant correlation between the perception of
the image of the body and that of the self-
esteem. Thus the higher the score of body
image, the lower the score of the perception of
the self-esteem (Pearson’s correlation coefficient
= -0.444, p<10
-3
).
4. DISCUSSION
4.1 Perception of the Body Image
Schilder defines the image of the body as "the
way our body appears to us" [14].
Patients with breast cancer present an alteration
of the body image that is expressed in several
dimensions: Social relations, physical well-being
and self-esteem [15].
A poorer body image score was noticed in 62%
of women. This proportion was lower in the study
of Dahl et al. [16]. In fact seventy-six breast
cancer survivors (31%) had poorer body image in
2004, and sixty-seven (27%) in 2007. Among
those 76 survivors who had a poorer body image
in 2004, 52 survivors (68%) also had a poorer
body image in 2007, whereas 24 survivors (32%)

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
9
had changed to a better body image. Among the
172 BCSs who had a better body image in 2004,
15 survivors (9%) had changed to a poorer body
image in 2007, whereas 157 survivors (91%)
retained a better body image over time.
In our study, no significant difference was found
between poorer and better body image according
to sociodemographic characteristics.
Marques et al. [17] found, as in our study, no
significant association between image of the
body and age (p=0.20). However, in 2001,
Hopwood et al. [13] noticed that young women
had a better body image. Bredart et al. [18] have
also highlighted more important concerns of the
body image among young patients.
Besides, concerning the civil status, Francisco
et al. [19] affirmed that single women were more
distressed by their body image (p=0.03). The
marital status had no impact on the body image
in our survey.
In our study, a greater proportion of women who
had a poorer body image had a history of
psychiatric pathologies (18.2% versus 2.1%
among better body image). This difference was
statistically significant (p=0.007). In Hannoun’s
study [20], a quarter of the women treated for
breast cancer took a treatment for anxiety,
depression or both. These disorders destabilize
the psychic homeostasis of women and therefore
disrupt the image they had of their bodies.
Moreover, according to Dahl et al. [16], poorer
body image was associated with poorer self-
rated health, chronic fatigue and mental distress,
and poorer generic and disease-related quality of
life in univariate analyses. Most of these
variables also significantly predicted poorer body
image 3 years later.
As in our study, Marques et al. [17] found no
significant association between the perception of
the body image and the time elapsed since the
discovery of the disease. Bredart et al. [18] have
noted a poorer body image beyond 6 months
after surgery by comparison to the first six
months following this intervention. However,
Hopwood et al. [13] have found higher scores on
the scale of body image at the end of the first six
months after the date of the first surgical
intervention.
The survey made by Shover et al. [21], on a
large group of women, confirmed that quality of
life was minimally affected when a partial
mastectomy or immediate breast reconstruction
was performed. The great majority of women
were well adjusted psychologically, rated their
sexual attractiveness positively, had happy
marital relationships, and were satisfied with their
sex lives. Concerning all of these dimensions,
less than 20% of women reported significant
distress.
In addition to the systemic treatment, surgical
treatment affects the image of the body.
Vanlerenberghe et al. [22] affirmed that
mastectomy, when it is indicated, is experienced
as a mutilation and an alteration of the female
identity and the body image. Of all time, breast
has always been a symbol of femininity. In daily
life, the absence of the breast and the
dissymmetry are very binding: fear of losing the
prosthesis, fear to be surprised nude in the
bathroom, etc. The nudity may be difficult to
assume and become particularly stressful. Two
types of pain can occur after breast surgery:
phantom breast pain and post mastectomy pain
syndrome [23].
Marques et al. [17], have found a better body
image score among women who underwent
radical surgery than among women who had
conservative one. This confirms that the
evaluation of the body image allows
differentiating groups of surgery characterized by
appearance changes. However, Shover et al.
[21] reported that conservative treatment can
cause more distress of the body image than a
radical treatment (p<0.001). In fact, 88% of
patients who had a conservative treatment were
not satisfied with the appearance of their breast.
According to Shover, women who had partial
mastectomy and those who underwent breast
reconstruction were similar on dimensions of
psychosocial adjustment and body image,
suggesting that the choice of the treatment
should be based on medical factors but also on
aesthetic outlook [21].
In the study of Dahl et al. [16], a significantly
greater proportion of women who underwent
breast reconstruction were among the breast
cancer survivors with the poorer body image.
58% of breast cancer survivors who were treated
with both modified radical mastectomy and
manually planned radiotherapy had a better body
image.
Vanlerenberghe et al. [22] have found that
radiotherapy alters the perception of the image of
the body. The skin is infiltrated, loses its

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
10
flexibility, and the breast is painful forbidding any
contact, patients often complains of burning
sensations.
More common adverse events of hormonal
therapy are weight gain (progestin), lot flushes
(oestrogen inhibitors, aromatase inhibitors),
vaginal dryness and atrophy, bone pain and
arthralgia (aromatase inhibitors). This treatment
alters the image of the body and the quality of
life of some patients [22]. However, in our study
the association endocrine therapy and the
perception of the image of the body were not
significant.
In addition, in our study we found a correlation
between the perception of the image of the body
and alopecia caused by chemotherapy (p=0.006)
which is consistent with the result found in the
study of Shover (p<0.001) [21].
4.2 Perception of the Self-esteem
Our patients had a low self-esteem in 78.4% of
cases with a mean score of 23.59±8.19. In the
study of Shover et al. [21] 29% of women had a
low self-esteem.
According to Gomes et al. [24], the minimum
score obtained was 19 points and the maximum
40, with a mean of 30.32± 4.58. Only one woman
(2.7%) presented low self-esteem, 16 women
(43.2%) had average self-esteem and 20 women
(54.1%) high self-esteem.
In our series, being married significantly affects
the perception of the self-esteem (p = 0.025).
Similarly Gomes et al. [24] have shown that 11
of the 20 women with high self-esteem score
had stable unions (It should be noted that
those married or living with a steady partner
were considered to be in a stable union).
The presence of the partner has been shown
to be significant in fighting the disease
and facilitated her family and social reintegration
[25].
According to Gomes et al. [24] there is a
significant relationship between age and self-
esteem. The prevalence of high self-esteem can
be explained by the mean age of the
respondents (56.11 years), as self-esteem tends
to increase with age [26]. This has also been
found by Johansson et al. [27], they reported
that being a single female, aged between 26 and
63 years and still working despite the disease,
foster a strong self-esteem.
In our study, no correlation between the
perception of the self-esteem and the level of
instruction was noted. However, Gomes et al.
[24], have shown a positive correlation between
educated women and a high self-esteem
(p<0.05). It is assumed that the higher the level
of education, the greater the access to
information and, consequently, the greater the
understanding of the situation. Women start to
value the fact that they are survivors of breast
cancer and attach less value to their body image.
They feel more peaceful, secure and confident,
which reflect positively in their self-esteem [24].
As in our study, Gomes et al. [24], found no
significant difference between low and more than
the average self-esteem according to the type of
treatment. The majority of the women in both
groups presented high self-esteem, with the
percentages being equivalent. Moreover,
concerning the complementary treatments,
among the seven women who underwent
neoadjuvant chemotherapy, four (54.15%)
presented average self-esteem and three
(42.85%) high self-esteem. Among the 15 who
underwent adjuvant chemotherapy, one (6.67%)
presented low self-esteem, six (40%) average
self esteem, and eight (53.33%) high self-
esteem. Of the eighteen women who underwent
radiotherapy, nine (50%) presented average self-
esteem, nine (50%) high self-esteem and, finally,
of the 29 who underwent endocrine therapy, 12
(41.4%) presented average self-esteem and 17
(58.6%) high self-esteem. Two patients who did
not receive neither chemotherapy nor hormonal
therapy had high self-esteem [24].
These findings are not in line with some studies
[28,29]. In Vieira and in Tavares studies, radical
surgery affected the self-esteem and body image
of the patients and was cited as a source of
emotional and physical distancing between
woman with mastectomy and her partner [24]. It
was noted that if surgery was performed on the
dominant side, the self-esteem scores tended to
be lower. Indeed, lymphodema could hinder the
return to normal daily activity and normal
relationships [30].
In our study, women exposed to chemotherapy-
induced alopecia had lower self-esteem (p =
0.014).
Despite knowing that chemotherapy and
hormonal therapy negatively influence the quality
of life of patients and their self-esteem, due to
the adverse effects (decreased physical function,

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
11
role performance and body image, and increased
symptoms of anxiety, fatigue, nausea, vomiting
and constipation) [31], the study of Gomes et al.
[24] did not encounter this result.
Also known as ‘reverse mastectomy’, breast
reconstruction is considered the most effective
method for the restoration of the psychological
well-being after mastectomy. It improves the
body outline, preserves or restores the personal
integrity, increases optimism for a cure, and
contributes to sexual identification, thus
increasing the self-esteem and improving the
body image [32]. However, for other women,
breast reconstruction is not desired, even when it
is encouraged by the doctors [33].
4.3 Pearson’s Correlation between the
Perception of Self –esteem and Body
Image
The reliability of the body image scale is
satisfactory (Cronbach alpha = 0.941). This
result is in line with what was found by Brédart et
al. [18] (Cronbach's alpha= 0.93) [19]. In the
study of Vallieres et Vallerand, the Cronbach
alpha values is equal to 0.89 for the self-esteem
scale. This result was consistent with ours
(0.929) reflecting a good internal consistency of
the items [34].
5. CONCLUSION
The results found in our study highlighted the
magnitude of the psychological pain experienced
by women with breast cancer. This type of
cancer requires an appropriate holistic support
(biopsychosocial) to ensure a better quality of
life. Despite the importance of the sufferance,
and the impact of this pathology on the
psychosocial life of the woman, few studies have
addressed this topic. Therefore, it is important to
initiate researches in this subject in order to
improve the wellbeing of women with breast
cancer.
CONSENT
As per international standard or university
standard, patient’s written consent has been
collected and preserved by the authors.
ETHICAL APPROVAL
It is not applicable.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
REFERENCES
1. Ferlay J, Soerjomataram I, Dikshit R, et al.
Cancer incidence and mortality worldwide:
Sources, methods and major patterns in
Globocan 2012. Int J Cancer. 2015;136
(5):E359-86.
2. Yankaskas BC. Epidemiology of breast
cancer in young women. Breast Dis. 2005–
2006;23:3–8.
3. Frikha M, Yaiche O, Elloumi F, et al.
Results of a pilot study for breast cancer
screening by mammography in Sfax
region, Tunisia. J Gynecol Obstet. 2013;
42(3):252–61.
4. Anderson MS, Johnson J. Restoration of
body image and self-esteem for women
after cancer treatment. Cancer Pract.
1994;2:345–349.
5. Merriam-Webster Dictionary.
Available:http://www.merriam-
webster.com/
(Accessed July 6, 2009)
6. Cash TF, Melnyk SE, Hrabosky JI. The
assessment of body image investment: An
extensive revision of the Appearance
Schemas Inventory. Int J Eating Dis.
2004;35:305-316.
7. Carmichael AR. Obesity and prognosis of
breast cancer. Obesity Rev. 2006;7:333-
340.
8. Rooney M, Wald A. Interventions for the
management of weight and body
composition changes in women with breast
cancer. Clin J Oncol Nurs. 2007;11:41-52.
9. Cash TF, Pruzinsky T, Eds. Body Image: A
handbook. New York: Guilford Press;
2002.
10. Branden N. Self-esteem: How to learn to
like yourself. São Paulo (SP): Saraiva;
2000.
11. White CA. Body image dimensions and
cancer: a heuristic cognitive behavioural
model. Psycho-Oncology. 2000;9:183-192.
12. Frédéric Fourchard A. Courtinat-Camps.
Overall and physical self-esteem in
adolescence. Elsivier Masson. 2013;61
(n6):333-94.
13. Hopwood P, Fletcher I, Lee A, et al. A
body image scale for use with cancer
patients. Eur J Cancer. 2001;37:189-197.

Ghali et al.; JAMMR, 23(4): 1-12, 2017; Article no.JAMMR.35567
12
14. Schilder P. The image of the body: Studies
of the constructive forces of the psyche.
Paris: Gallimard; 1980.
15. Reich M. Cancer and body image: Identity,
representation and symbolism. Inf
Psychiatr. 2009;85:247-54.
16. Falk Dahl CA, Reinertsen KV, Nesvold IL,
et al. A study of body image in long-term
breast cancer survivors. Cancer. 2010;
116(15):3549-57.
17. Marques A, Cristina M, Moreira H. The
portuguese version of the body image
scale (BIS) – psychometric properties in a
sample of breast cancer patients.
European Journal of Oncology Nursing.
2009;1–8.
18. Brédart A, Swaine Verdier A, Dolbeault S.
French adaptation of the Body Image
Scale (BIS) scale assessing the perception
of body image in women with breast
cancer. Psycho-Oncology. 2007;1(1):24-
30.
19. Fobair P, Stewart SL, Chang S. Body
image and sexual problems in young
women with breast cancer.
Psychooncology. 2006;15(7):579-94.
20. Hannoun-Levi JM. Treatment of breast and
uterine cancer: Physiological and
psychological impact on sexual function.
Cancer / Radiotherapy. 2005;9(3):175-82.
21. Schover LR, Yetman RJ, Tuason LJ, et al.
Partial mastectomy and breast
reconstruction. A comparison of their
effects on psychosocial adjustment, body
image, and sexuality. Cancer. 1995;
75(1):54-64.
22. Vanlerenberghe E, Sedda AL, Ait-Kaci F.
The impact of gynaecological cancers on
woman's sexuality and her couple. [Article
in French]. Bull Cancer. 2015;102(5):454-
62.
23. Laurent Labrèzea, Florence Dixmeriasa,
Dominique Monnina, et al. A new post-
mastectomy syndrome intensity monitoring
score (MPPS). Pain Assessment -
Diagnosis – Treatment. 2010;11:158-164.
24. Gomes NS, Riul S. Evaluation of the self-
esteem of women who had undergone
breast cancer surgery. Text context
nursing, Florianópolis. 2013;22(2):509-16.
25. Vieira CP, Lopes MHBM, Shimo AKK.
Feelings and experiences in the lives of
women with breast cancer. Rev Esc
Enferm USP. 2007;41(2):311-6.
26. Terra FS. Evaluation of anxiety,
depression and self-esteem in public and
private university nursing professors
[thesis]. Ribeirão Preto (SP): University of
São Paulo, Ribeirão Preto College of
Nursing; 2010.
27. Inez J, Carina B. Social support and self-
esteem in patients afflicted with cancer in
the reproductive organs, including breasts.
Austral-Asian Journal of Cancer. 2003;
2:116-123.
ISSN: 0972-2556
28. Vieira CP, Queiroz MS. Social
representations about female cancer:
Experience and professional performance.
Psicol Soc. 2006;18(1):63-70.
29. Tavares JSC, Trad LAB. Families of
women with cancer: Challenges
associated with care and coping factors.
Interface (Botucatu). 2009;13(29):395-408.
30. Silva G, Santos MA. Stressors in breast
cancer posttreatment: A qualitative
approach. Rev Latino-Am Enfermagem.
2010;18(4):688-95.
31. Nicolussi AC, Sawada NO. Quality of life of
breast cancer patients in adjuvant therapy.
Rev Gaúcha Enferm. 2011;32(4):759-66.
32. Braganholo LP. The non-performing breast
reconstructive surgery: associated factors,
quality of life and self-esteem
[dissertation]. Ribeirão Preto (SP): School
of Nursing, University of São Paulo; 2007.
33. Henry M, Baas C, Mathelin C. Breast
reconstruction after breast cancer:
Reasons for refusal why do women refuse
reconstructive breast surgery after
mastectomy? Gynecology and Obstetrics
& Fertility. 2010;38:217-223.
34. Evelyne F Vallieres, Robert J Vallerand.
French translation and validation of
Rosenberg's self-esteem scale. Int. J. of
Psychology. 1990;25:305-16.
_________________________________________________________________________________
© 2017 Ghali et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Peer-review history:
The peer review history for this paper can be accessed here:
http://sciencedomain.org/review-history/20463