“I know why I have the scars that I do, and the bottom line is that I need them to exist”: Cancer treatment and women’s body image

With October being Breast Cancer Awareness month, we revisit this great post exploring the impact of breast cancer treatment on women's body image. 

The month of October is a time when charities, individuals, brands and businesses in the UK raise awareness of diagnosis and treatment of breast cancer. Breast cancer is the most common cancer affecting women in the UK, and in any one month around 5000 women will be diagnosed with the disease (Breast Cancer Care, 2018). Surgery, chemotherapy, radiotherapy and hormone therapy are used to treat women affected, and cancer survival has doubled in the last 40 years (Cancer Research UK, 2018).  

Procedures and therapies impact on women’s bodies physically and emotionally as they experience the changes caused by the disease and treatments.  Women might find it difficult to come to terms with a body that differs from idealised media images, and previous work on women’s body image and well-being after cancer treatment has focussed mostly on the negative impacts (e.g. Baucom, Porter&  Kirby, 2006). To understand more fully women’s experiences of cancer treatment and body image from their own perspectives, and to enable reports of both positive and negative experiences, we gave women space to report anything they felt was relevant.  We did not want to assume that the experience would be wholly negative, and so we used methods that enabled women to share as much as they were comfortable with, and in their own words.

Study 1: An Analysis of Women’s Written Accounts

Design and Methods
Our first study (Grogan & Mechan, 2016) was an investigation of women’s experiences of mastectomy with and without reconstruction/augmentation. We focused in particular on younger women (aged 45 years or under at diagnosis) who have been underrepresented in research on women’s experiences of mastectomy in the past (Holland, Archer, and Montague, 2014) and our key question was What are the impacts of mastectomy on younger women’s body image?

Image: Cancer Research UK
Women were invited to take part in the study through a UK-based online support network. This network is only open to young women with a diagnosis of breast cancer, and the second author is a member of this online group. Forty-nine women, aged 29-53 years (mean age 39 years) who had had bilateral (n = 8) or unilateral (n = 41) mastectomy took part in the study. 

To encourage disclosure and ensure that women felt comfortable discussing their experiences, we asked participants to complete a series of open-ended questions anonymously through an online questionnaire. As part of these questions, women were asked “In addition to the removal of the cancer, please share with us what was important to you when you were advised or decided (prophylactic) to have one or both of your breast removed”, and “How do you feel about your body image currently, has this changed since diagnosis and if so how has it changed?”  Thematic analysis was used to identify themes.

Findings
One key theme was the desire to survive, which dominated women’s experiences at the early stages from diagnosis to mastectomy. Women distanced themselves from the infected parts of their breasts, which were objectified and seen as separate from their well bodies. After treatment, many women felt self-conscious about their changed bodies, though others reported that having good levels of body confidence before they had cancer treatment protected them against some of the more negative impacts. 

Many had renegotiated how they should be treated as women “I am who I am and I don’t go out to impress people” and recognised that they would need to be realistic and habituate to their new, changed bodies:  “I'd obviously prefer to be how I was but had no choice but to have surgery so am just accepting of the scars and reconstruction”. For some participants, getting to recognise and feel comfortable with their post-mastectomy bodies was challenging, and some were concerned about showing their scars. Others took a pragmatic view, seeing scarring as a necessary result of treatment that had enabled them to survive, “I know why I have the scars that I do, and the bottom line is that I need them to exist”. Some women even reported feeling proud of their scars as these represented their successful ‘battle’ for survival “My scars are my war wounds of life. I don’t hide away from them. I'm proud of them. Yes my breasts are different and not natural but that doesn't change who I am”.

Study 2: Focus Group with Women Who Have Experienced Cancer Treatment
Design and Methods
In our second study (Grogan, Mechan, Persson, Finley, & Hall, 2017) , we used focus group methodology to give women some control over the agenda, leaving  space for unexpected findings  and positive as well as negative constructions of the body. Our key question was How do women construct body image following cancer treatment?

Women were invited through an advertisement placed on a UK cancer charity website, and were asked to take part in a study to investigate stories and personal experiences of cancer diagnosis and treatment. Four women aged 32-67 years who had experienced cancer treatment for breast or bowel cancer took part in one focus group, where they were encouraged to talk freely about their experiences of cancer treatment.

Our analysis aimed to help us to understand how women who had undergone breast or bowel cancer treatment reflected on their everyday experiences, and in particular, we were interested in how these women’s talk resisted social norms around women’s bodies and cancer. 

Findings
Women identified both positive and negative impacts, talking about concealing their bodies and illness from public interest and judgment, sometimes wanting to blend in by not drawing attention to themselves in social situations, and also about developing increased trust in, and acceptance of, their changed bodies. Women aimed to present their post-cancer bodies as positive whilst not necessarily feeling comfortable with their naked bodies. Participants spoke about the use of cosmetics, wigs, prosthetic devices, different types of clothing or alternative ways of wearing clothing in order to hide any perceived body imperfections, and also spoke about the management of their naked bodies by “hiding” them in public spaces such as public changing rooms.  The degree to which women reported engaging in these activities did not necessarily relate to the level of scarring. 

Despite issues with the management of their bodies in public, some participants talked openly about how they had developed renewed trust and respect for their bodies as a result of cancer treatment and survival.  For instance one woman talked about having “a really huge respect” for her body, and another discussed how she has developed “trust” and “new found respect” for her body since cancer treatment. All participants indicated they accepted their post-cancer bodies. For instance, “I sort of, I have accepted sort of who I am“.

Summary and Conclusions 
Women who completed our online questionnaire and who took part in our focus group presented much more positive stories than we had expected based on work suggesting that mastectomy and other cancer-related treatments produce mainly negative impacts on women’s body image and wellbeing. Women had been inspired to create new body identities as a result of cancer treatment, and some women said that their scars were like war wounds, symbols of survival, suggesting a good level of perceived control and self-efficacy.  Women used acceptance discourses and talked about renegotiating gender identity. In both studies, we were struck by the variability in accounts of women experiencing a relatively similar life event. It is therefore important that health professionals and others do not expect homogenous patterns of negative responses in women who have had cancer treatment, so that they are able to provide tailored support if and when needed. 


Sarah Grogan is Professor of Psychology, Health and Wellbeing at Manchester Metropolitan University. She is interested in body image and links between body image and health-related behaviours such as smoking, UV protection, and alcohol consumption as well as media and other social influences on body image. 
Jayne Mechan is Senior Lecturer in Fashion Technology in the Manchester Fashion Institute, Manchester Metropolitan University. She is interested in mechanisms of body representation and diversity within the fashion industry. 

References
Baucom, D., Porter, L.& Kirby, J. (2006). Psychosocial issues confronting young women with breast cancer. Breast Disease, 23, 103-113. https://content.iospress.com/articles/breast-disease/bd000209
Breast Cancer Care (2018).  Facts and statistics. Available at: https://www.breastcancercare.org.uk/about-us/media/facts-statistics (accessed 26 August 2018)
 Cancer Research UK (2018) Cancer statistics for the UK. Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics-for-the-uk#heading-Zero (accessed  10 August 2018).
Grogan, S. &  Mechan, J. (2016). Body Image after Mastectomy: A Thematic Analysis of Younger Women’s Written Accounts. Journal of Health Psychology. E-pub ahead of print 24 Feb 2016. http://dx.doi.org/10.1177/1359105316630137
Grogan, S., Mechan, J., Persson, S., Finlay, S., & Hall, M. (2017). I’ve got a very dichotomous difference in the way that I perceive myself”: Positive and negative constructions of body image following cancer treatment. Journal of Health Psychology. E-pub: https://doi.org/10.1177/1359105317730896
Holland, F., Archer, S., & Montague, J. (2016). Younger women’s experiences of deciding against delayed breast reconstruction post-mastectomy following breast cancer: An interpretative phenomenological analysis, Journal of Health Psychology, 21(8), 1688-1699. http://dx.doi.org/10.1177/1359105314562085



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