How to Address Body Image Concerns in Patients with Breast Cancer

It’s incredibly common for people with newly-diagnosed breast cancer to worry about how their bodies will change. It’s also common for them to have concerns about their bodies during and after treatment. This is true whether they respond well to treatment and go into remission quickly or have a more complicated disease course.

Everyone’s body changes through breast cancer and is usually left with a scar. It may be a small scar from a needle biopsy or a series of scars from a mastectomy. Or even multiple well-placed scars from careful breast reconstruction. Their bodies have changed, and the scars are a constant reminder.

I hear patients worry that they shouldn’t talk about these concerns. They worry that they shouldn’t be worried or anxious about how their bodies look and feel, post-diagnosis or post-treatment. They express that they’re “supposed” to feel happy to be alive—and that people will look down on them for being anything less than that.

However, as palliative care clinicians, we can and should give patients the “permission” and space to feel their feelings and share their concerns, whatever they may be, and help them improve their quality of life.

Breast cancer patients often experience depression, anxiety, and stress. We must also understand the toll breast cancer, and its treatment can take on self-image. Research shows that the loss of a breast can have a “dramatic impact” on a woman’s body image. In fact, mastectomy and reconstruction have been associated with greater body image problems in studies of younger women who’ve had breast cancer, especially those who are sexually active.

But it’s not just their breasts. They look in the mirror and see a body they don’t quite recognize. In addition to changes to their breasts, they may have gained weight or lost their hair as a side effect of chemotherapy. If they went through radiation, they may have experienced changes to their skin, too.

“Negative body image among breast cancer survivors includes dissatisfaction with appearance, perceived loss of femininity and body integrity, reluctance to look at one’s self naked, feeling less sexually attractive, self-consciousness about appearance, and dissatisfaction with surgical scars,” wrote the authors of a study about the impact of mastectomy on body image for women with breast cancer in The Journal of Breast Health.

This tells us that we must be conscious of the potential impact that breast cancer can take on self-image—and that we should be on the watch for any signs of struggle.

As an oncologist and palliative care physician, I sometimes suspect that a patient may be struggling with body image issues related to their diagnosis and treatment. I honor those feelings and give my patients space to discuss them. This helps me determine whether they may benefit from a referral to a mental health professional.

But I also don’t want to lead my patients into thinking there is a “right answer”. If I say, “Oh, this must be so hard on you,” then my patient might start to worry about whether or not their experience is too hard or not hard enough. We never want to suggest that they should or shouldn’t feel any particular way.

So, I deliberately ask questions that won’t insinuate anything. I might say, “How are you doing with the physical changes?” And then I sit back and let them talk, giving them space to tell me how they feel.

When I ask my patients how they feel about their bodies and the physical changes that have occurred, I pay close attention to their responses—not just what they tell me but how they tell me. These three factors help me shape the next steps:

If someone with a half-inch scar, but no other noticeable changes to the contour of their breast, describes feeling terribly disfigured and unable to bear the changes to their body, that suggests to me that they may be struggling with some dysmorphia.

If the thoughts or feelings about changes in their body keep them from being able to do or enjoy daily activities.

If time has passed after undergoing treatment, they are still uncomfortable with their appearance and haven’t reached an ‘okay place’ with the changes to their body.

Depending on their responses, I may suggest that they would benefit from assistance addressing body image concerns. For some, this means talking to a mental health professional about their psychological distress. Others may benefit from a peer support group because connecting with others who know what they’re going through can be comforting.

To make a referral, I’d start by consulting with a social worker on your team. They’ll help you determine available options for supporting your patients. You may also need to check on the patient’s insurance plan to find out what’s covered, depending on whether they would benefit from seeing a psychologist, counselor, or psychiatrist.

Note that psychiatrists tend to focus on medication management, which may or may not be necessary for your patient. Talk therapy may be more useful. You might refer them to a psychologist or social worker who specializes in cognitive behavioral therapy (CBT), which has been shown to reduce pain after treatment in breast cancer patients. It can also help change negative thought patterns around their appearance and address fears about their cancer recurring.

I also recommend preparing and familiarizing yourself with support resources in your community. Be ready to provide resources to your patient(s), so they don’t have to do the work themselves. For example, in New York, I might recommend that patients seek out resources such as the Red Door Community, which provides support to cancer patients and their families, or Sharsharet, a Jewish organization for breast and ovarian cancer patients, with a focus on younger patients.

Preparing also means knowing when to refer a patient back to their breast or plastic surgeon. In some cases, a patient who is self-conscious or unhappy with their appearance may benefit from an additional intervention—perhaps another surgery. While I cannot make that determination, I can definitely refer them for an evaluation. I once referred a patient back to her surgeon, and she needed to have her breast implants removed. Another patient needed a scar revision.

We can tremendously benefit our patients by providing them with space to talk about their experiences. Expressing their feelings about their bodies can be very therapeutic for patients. But we should also be prepared to refer them onward if they need more specialized care.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.