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REVIEW
Efficacy of psychosocial and physical activity‐based
interventions to improve body image among women treated
for breast cancer: A systematic review
Helena Lewis‐Smith |Phillippa Claire Diedrichs |Nichola Rumsey |Diana Harcourt
Centre for Appearance Research, University of
the West of England, Bristol, UK
Correspondence
Helena Lewis‐Smith, Centre for Appearance
Research, University of the West of England,
Coldharbour Lane, Bristol, BS16 1QY, UK.
Email: helena.lewis‐smith@uwe.ac.uk
Funding information
University of the West of England
Abstract
Objective: Body image concerns warrant attention among women who have under-
gone treatment for breast cancer, due to their significant consequences for psycho-
logical and physical health, and interpersonal relationships. This paper systematically
reviews the effectiveness of interventions on body image outcomes among this
group, in order to inform health care provision and strategic directions for research.
Methods: Fourteen electronic databases were searched for articles published
between 1992 and 2017 that evaluated interventions with women who had under-
gone treatment for breast cancer in controlled trials with at least one body image
measure. Data were extracted and studies were assessed for their methodological
quality using the Cochrane Collaboration tool for assessing risk of bias.
Results: Twenty‐one articles evaluating 26 interventions met inclusion criteria.
Nine interventions significantly improved body image at either post‐test or follow‐
up (ds = 0.15‐1.43), with none reporting sustained effects across all time points. Effec-
tive interventions comprised psychotherapy, psychoeducation, or physical activity,
were delivered at different treatment stages and mostly adopted a multisession,
face‐to‐face, group format. However, only 4 interventions were evaluated within
methodologically rigorous studies and are therefore recommended for use by health
professionals aiming to improve the body image of women at different stages of treat-
ment for breast cancer.
Conclusions: To advance the field, we recommend a less biomedical disease‐and
treatment‐focused approach to interventions, and instead a more biopsychosocial
theoretical approach targeting broader modifiable psychosocial influences upon body
image. Replication and randomised controlled trials of greater rigour are also required
to improve the methodological quality of studies.
KEYWORDS
body image, breast cancer, intervention, oncology, systematic review
1|BACKGROUND
Treatment for breast cancer can have a significant impact on bodily
appearance, sensations, and function, all of which can impose adverse
and enduring effects on body image.
1
The consequences of poor body
image on physical and psychological health, identity, quality of life, and
interpersonal relationships among this group can be grave and long
lasting.
2
The development and delivery of effective interventions for
body image among women who have undergone treatment for breast
cancer is therefore indicated. This paper systematically reviews the
Received: 23 March 2018 Revised: 1 August 2018 Accepted: 20 August 2018
DOI: 10.1002/pon.4870
Psycho‐Oncology. 2018;1–13. © 2018 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pon 1
current status of evidence for psychosocial and behavioural interven-
tions for women who are currently undergoing, or have previously
undergone, treatment for breast cancer on body image outcomes to
inform health care provision and to strategically advance research in
this field.
1.1 |Body image concerns among women treated
for breast cancer
Breast cancer is the most commonly diagnosed cancer among women
worldwide.
3
However, survival rates have improved, with 5‐year sur-
vival rates at 81.8% to 91% across the United States and Europe.
4-6
This promising prognosis indicates that growing numbers of women
are living with the consequences of the disease and its treatment.
One major consequence is temporary or permanent changes to
appearance, sensations, and function. Surgery may lead to breast
asymmetry, scarring, sensation loss, and lymphedema, whilst the side
effects of adjuvant therapies can include hair loss and thinning,
fatigue, weight fluctuation, dermatitis, skin and nail discolouration,
and the exacerbation of menopausal symptoms.
These extensive treatment‐induced changes can cause substantial
distress for many women, imposing adverse effects on body image
both during and following treatment.
1,7,8
Up to 77% of this group
experience some degree of body image concern,
9
with longitudinal
research indicating little improvement up to 5 years following treat-
ment.
1,10
These findings are concerning, as prospective research indi-
cates that poor body image can lead to elevated levels of anxiety,
depression, and sexual and intimacy concerns, and increased risk of
mortality.
2,11
1.2 |Interventions for women treated for breast
cancer
The importance of addressing the psychosocial consequences of can-
cer diagnosis and treatment has been increasingly recognised at an
international level by governments, health policy and services, and
community organisations.
12,13
Breast Cancer Care, the leading breast
cancer charity in the United Kingdom, has called for more support spe-
cifically to address body image concerns among women treated for
breast cancer.
14
Nonetheless, body image support currently available
is often camouflage‐based and targets temporary appearance changes
(e.g., hair loss). For example, “Look Good, Feel Better”is a globally
delivered skin care and make‐up workshop, which teaches women
make‐up techniques to help manage eyebrow and eyelash loss. Psy-
chosocial support available following active treatment, such as the
UK‐based “Moving Forward”group courses, provides support and
information on a wide array of issues, within which body image is only
briefly explored. Whilst women can benefit from these free services,
they have not undergone rigorous evaluation. Consequently, their
impact on body image remains unknown. This emphasises the impor-
tance of developing and evaluating psychosocial interventions to
address body image concerns for women at different stages of breast
cancer treatment. Health psychology practitioners and researchers,
with their specific expertise in managing the psychosocial outcomes
associated with physical illness, are well positioned to inform, develop,
and deliver these interventions.
Fingeret, Teo, and Epner
15
provided a promising start with regard
to appraising psychosocial interventions that target body image con-
cerns among women with breast cancer. However, the interventions
were not reviewed systematically and their evaluative studies were
not appraised in relation to their methodological rigour. Given the
prevalence of sustained body image concerns experienced by this
group, a rigorous evaluation of current psychosocial and behavioural
interventions and the methodological quality of studies is necessary
to provide robust evidence‐based recommendations for intervention
delivery and dissemination for health professionals and to provide
strategic direction for future research. This paper therefore reports a
systematic review of studies evaluating psychosocial and behavioural
interventions delivered to women who have undergone treatment
for breast cancer on body image outcomes.
2|METHODS
This systematic review was conducted in compliance with the
Cochrane Handbook for Systematic Reviews of Interventions.
16
All
methods were established prior to the conduct of the review.
2.1 |Search strategy
Searches were conducted through the following electronic databases:
PsycINFO, MEDLINE, CINAHL, AMED, ASSIA, British Nursing Index,
Embase, Science Direct, Social Sciences Citation Index, Science Cita-
tion Index, PubMed, and the Cochrane Library. Five additional data-
bases were searched to identify any grey literature: Web of
Knowledge, Zetoc, EThOS, National Research Register, and UK Clini-
cal Research Network. References of included articles were screened
manually for additional studies. Combinations of population, interven-
tion, and outcome terms guided the searches, including women,female,
breast cancer, and breast oncology as population terms. Intervention
terms included psychological intervention/therapy,psychosocial inter-
vention,program,cognitive behavioural therapy,counselling,education,
and self‐help. Outcome terms included body image,body dissatisfac-
tion/satisfaction,body esteem/appreciation,appearance,shape con-
cern/dissatisfaction, and weight concern/dissatisfaction. Searches were
initially conducted in January 2013 and were updated in
November 2017.
2.2 |Eligibility criteria
To qualify, articles had to be published in English from 1992 to 2017
to provide a current review. The sample had to be comprised of
women with a mean age ≥35 to reflect the rarity of breast cancer
in younger women.
17,18
Participants had to be currently undergoing,
or had previously undergone, any form of treatment for breast cancer
at any stage (including ductal carcinoma in situ or metastatic disease).
Studies with participants with a clinically diagnosed co‐morbid condi-
tion (e.g., eating disorders) were excluded. Interventions could adopt
any form of psychosocial or behavioural approach. These included
psychotherapeutic (i.e., provision of formal psychological therapy or
2LEWIS‐SMITH ET AL.
therapeutic technique, e.g., cognitive behavioural therapy),
psychoeducational (i.e., provision of knowledge about the condition
and coping skills, but no formal interactive psychotherapy), physical‐
activity‐based (i.e., guidance or facilitating of any form of physical
activity, e.g., strength training, jogging), and camouflage‐based
(i.e., concealing or altering appearance, e.g., make‐up workshops)
approaches. Couple‐based interventions were excluded given that
they are not relevant to all women. Whilst interventions did not have
to assert a primary aim of improving body image, those with the pri-
mary aim of weight‐loss were excluded, as the focus of the review
was to identify interventions which improved improve body image,
without necessarily altering weight. Literature reviews and meta‐anal-
yses were also excluded. Studies had to compare the intervention
group with a passive (e.g., waitlist) or active (alternative intervention)
control group. Body image, defined as “a person's perceptions,
thoughts and feelings about his or her body”
19
: (p.3), had to be mea-
sured as an outcome variable. This was ascertained by the reviewers
(of the systematic review), as opposed to the original authors. Quanti-
tative and mixed methods were included, whilst qualitative‐only
methods were excluded. Posttest only study designs were excluded,
20
however, due to ethical issues, random allocation was not a
necessity.
21
Identified abstracts were reviewed against the eligibility criteria
by the first author, and potentially relevant abstracts were subse-
quently screened by the second and fourth authors. Following this,
the first, second, and fourth authors independently screened the full‐
texts of these articles. Any discrepancies in screening decisions were
discussed and resolved by consensus. See Figure 1 for the process
and outcome of the search.
2.3 |Data extraction
Using a standardised data extraction form and protocol (see S1)
adapted from the Cochrane Collaboration,
16
the first author extracted
the following information from each final paper: intervention approach
and theoretical basis, intervention dose and format, facilitator details
(training, profession, and number), participant details (number, age,
treatment), outcomes, and data analysis. The data extraction forms
were checked for accuracy and completeness by the fourth author.
Any inconsistencies were resolved by reviewing the papers collabora-
tively. Extracted data for each study was compiled and is presented in
Tables 1 and 2.
2.4 |Appraisal of intervention effectiveness
An intervention was considered effective if there was a significant
improvement at posttest and/or at follow‐up among the intervention
group, relative to the control group. Cohen's deffect sizes were calcu-
lated by dividing the difference between posttest group means by the
pooled standard deviation.
44
Cohen's deffect sizes were calculated,
whereby d= 0.2 was considered a “small”effect size, d= 0.5 was a
“medium”effect size, and d= 0.8 was a “large”effect size.
45
2.5 |Appraisal of study quality
The methodological quality of the final included studies was evaluated
using the Cochrane Collaboration tool for assessing risk of bias.
16
In
concordance with the tool, each domain of bias was judged to be of
high or low risk of bias or as an unclear risk if there was insufficient
FIGURE 1 PRISMA flow diagram illustrating
the original process of screening and
identification of studies in January 2013 and
including the additional studies from the
updated search in November 2017.
a
Two
studies evaluated the same intervention at
different time points and are thus regarded as
one study
LEWIS‐SMITH ET AL.3
TABLE 1 Characteristics of included studies
Authors
Intervention
Follow‐up
Evaluation
Dose (Sessions) Format Facilitator Participants/Sample Outcome Results
Approach
Theoretical
Basis # Mins
Face‐to‐Face/
Remote
Group/
Ind Trained Profession n M age (SD)
Stage of
Treatment n/Condition Posttest Follow‐up
Interventions with significant improvements on body image at follow‐up evaluation only and not at post‐intervention
Björneklett et al
(2013,
2012)
22,23a
Multimodal
support
programme
None 1.2 months
2.6 months
3.1 year
4.6.5 years
7 (+4) 1 day Face‐to‐face Group Y Multiple U 57.8 Postradio, 13%
mast, 77% cons,
42% chemo
IG: 191
CG: 191
N
a1
1. N
a1
2. N
a1
3. N
a1
4. Y(0.23)
a1
Hsu et al
(2010)
24
Informational
and emotional
consultation
None 2 months 2 120 Face‐to‐face Ind U Author 1 49.2 Cur. mast (no recon),
no chemo
IG: 32
CG: 31
N
b
Y(1.40)
b
Interventions with significant improvements on body image at post‐intervention only
Fadaei et al
(2011)
25
REBT None No follow‐up 6 90 Face‐to‐face Group Y Psychiatrist 1 IG: 43.5
(7.6) CG:
44.2 (7.1)
Postmast, received
chemo or radio
IG: 32
CG: 40
Y(1.43)
b
‐
Hamzehgardeshi
et al (2017)
26b
Counselling None No follow‐up 6 90 Face‐to‐face Group Y Midwife 1 IG: 46.8
(6.9) CG:
48.9 (5.9)
Posttreatment,
100% mast,
100% horm
IG: 40
CG: 40
Y
b
‐
Mehnert et al
(2011)
27
Multicomponent
exercise
programme
None No follow‐up 20 90 Face‐to‐face Group Y Physiotherapist
and sports
therapist
1 51.9 (8.5) Postchemo and/
or radio, 39%
mast, 59%
cons
IG: 30
WL: 28
Y(0.69)
b
‐
Pintado and
Andrade
(2017)
28
Mindfulness
and yoga
programme
None No follow‐up 8 120 Face‐to‐face Group U Unknown U 49.3 Posttreatment, 55%
mast, 45% cons,
97% chemo +
radio + horm
IG: 15
Active CG
(beauty
sessions):
14
Y(1.37)
b
‐
Rahmani and
Talepasand
(2015)
29c
Mindfulness
and yoga
programme
None 2 months 8 120 Face‐to‐face Group Y Clinical
psychologist
2 IG: 43.3
(3.1)
CG: 44.8
(3.3)
Targeted women
with fatigue
IG: 12
CG: 12
Y(1.16)
a1
N
a2
N
a1
N
a2
Salonen et al
(2009)
30
Telephone
social
support
None No follow‐up 1 M = 14 Remote Ind Y Physiotherapist 1 IG: 57
CG: 56
1‐week post‐surgery:
49% mast, 51%
cons, no adjuvant
therapy
IG: 120
CG: 108
Y(0.21)
a1
‐
Speck et al
(2010)
31
Strength
training
None No follow‐up 96 90 Face‐to‐face
and remote
Group Y Fitness
Instructor
1 56.5 Posttreatment, with
lymphedema (48%),
or at risk (52%),
75% chemo, 77%
radio
IG: 113
CG: 121
Y(0.25)
f
(0.30)
f1
(0.02)
f2
(0.15)
f3
‐
Interventions with no significant improvements on body image at post‐intervention
Beatty et al
(2010)
32
Self‐help
workbook
None 3 months Remote Ind 55.2
(12.7)
Post‐surgery: 43%
mast, 53% cons,
63% chemo, 67%
radio
IG: 25
Active CG
(info only):
24
N
a1
N
a1
(Continues)
4LEWIS‐SMITH ET AL.
TABLE 1 (Continued)
Authors
Intervention
Follow‐up
Evaluation
Dose (Sessions) Format Facilitator Participants/Sample Outcome Results
Approach
Theoretical
Basis # Mins
Face‐to‐Face/
Remote
Group/
Ind Trained Profession n M age (SD)
Stage of
Treatment n/Condition Posttest Follow‐up
Dibbell‐Hope
(2000)
33
Dance
therapy
None 3 weeks 6 180 Face‐to‐face Group U Dance
therapist
1 54.7 Post‐treatment, 81%
mast, 10% recon,
21% chemo, 19%
radio
IG: 15
WL: 16
N
d
N
d
Duijts et al
(2012)
34
1. CBT
2. Exercise
3. CBT +
exercise
None 6 months 1.6
2.12
3.18
1.90
2.150‐180
3.90+(150‐
180)
1. Face‐to‐
face
2. Remote
3. Face‐to‐
face +
remote
1.Group
2.Ind
3.Group
+ Ind
Y 1. Clinical
psychologist
and clinical
social workers
2. Physiotherapists
1.1
+3
2.1
48.2 (5.6) Targeted women
with menopause,
50% mast, 91%
chemo, 86% horm
1.109
2.104
3.106
WL: 103
1. N
a1
2. N
a1
3. N
a1
1. N
a1
2. N
a1
3. N
a1
Helgeson et al
(1999)
35d
1. Education
2. Peer
discussion
3. Education +
peer discussion
None 6 months 8 1.45
2.60
3.45
+60
Face‐to‐face Group Y 1. Multiple
2. Oncology
nurse and
social worker
2 48.25
(9.64)
Postsurgery and cur.
chemo, 32% mast,
68% cons
1.79
2.74
3.82
CG: 77
1. N
j
2. N
j
3. N
j
1. N
j
2. N
j
3. N
j
Jun et al
(2011)
36
Sexual life
reframing
programme
None No follow‐up 6 120 Face‐to‐face Group U Authors 1 45.7 Post‐treatment, 60%
mast, 40% cons,
100% chemo, 56%
radio, 78% horm
IG: 22
WL: 23
N
e1
‐
Mock et al
(1994)
37e
Exercise (a)
and support
group (b)
Roy
Adaptation
Model
No follow‐up U U a: Remote
b: Face‐to‐
face
a: Ind
b: Group
Y a: Authors
b: CNS
a: U
b: 1
44 Cur. chemo
(postsurgery), 7%
mast + no recon,
14% mast + recon,
79% cons
IG: 9
CG: 5
N
h1
N
i
‐
Pinto et al
(2005)
38
Physical
activity
Trans‐theoretical
Model of
Behaviour
Change
No follow‐
up
12 U Remote Ind U Authors 1 53.1 (9.7) Post‐treatment, 22%
mast + no recon,
7% mast + recon,
76% cons, 59%
chemo, 72% radio,
65% horm
IG: 39
CG: 43
N
c
‐
Quintard and
Lakdja
(2008)
39
Beauty
treatment
None 3 months 1 U Face‐to‐face Ind Y Beauty
therapist
2 50%
40‐50
1‐week post‐surgery:
9% mast, 91% cons
IG: 50
CG 50
N
g
N
g
Sandel et al
(2005)
40
Dance and
movement
programme
None No follow‐up 18 60 Face‐to‐face Group Y Author 1 61 Posttreatment, 71%
mast + no recon,
21% mast + recon,
8% cons, 8% cur.
chemo, 8% cur.
radio
IG: 19
WL: 19
N
b
‐
Scheier et al
(2005)
41f
1. Education
2. Nutrition
None 9 months 4 120 Face‐to‐face Group Y 1. Multiple
2. Nutritionist
1.2
2.1
44.2 Posttreatment: 18%
mast,76%cons,16%
chemo, 22% radio,
61% chemo + radio,
57% horm
1.70
2.78
CG: 76
1. N
k
2. N
k
1. N
k
2. N
k
(Continues)
LEWIS‐SMITH ET AL.5
TABLE 1 (Continued)
Authors
Intervention
Follow‐up
Evaluation
Dose (Sessions) Format Facilitator Participants/Sample Outcome Results
Approach
Theoretical
Basis # Mins
Face‐to‐Face/
Remote
Group/
Ind Trained Profession n M age (SD)
Stage of
Treatment n/Condition Posttest Follow‐up
Svensk et al
(2009)
42g
Art therapy None 6 months 5 U Face‐to‐face Ind Y Art
therapist
1 Median:
IG: 59.5
CG: 55
Cur. radio, 24% mast,
76% cons, 46%
chemo, 41% horm
IG: 20
CG: 21
N
a1
‐
Vito
(2007)
43
Yoga None No follow‐up 16 90 Face‐to‐face Group Y Yoga
instructor
2 50.96
(10.02)
Post‐treatment, 52%
mast, 40% cons,
68% chemo, 60%
radio
IG: 13
WL: 12
N
c
‐
Abbreviations: N/A, not applicable; REBT, Rational Emotive Behaviour Therapy; CBT, cognitive behaviour therapy; #, number of session; Y, yes; N, no; U, unclear; CNS, cancer nurse specialist; IG, intervention group; CG,
control group; WL, waitlist control condition; mast, mastectomy; recon, breast reconstruction; cons, breast conserving surgery; chemo, chemotherapy; radio, radiotherapy; horm, hormonal therapy; cur., currently under-
going; significant improvements in Body Image where P< .05 indicated by Y/N; Cohen's din brackets if Y; measures in superscript (eg,
a
and
b
; refer to Table 2).
a
A multimodal residential‐based programme, including education, psychological support, relaxation, dance, and social activities. Facilitators included oncologists, social workers, a psychologist, an art therapist, massage
therapists, a dietician, and a person trained in mental visualisation. A follow‐up session of 4 residential days took place 2 months later.
b
Unable to calculate effect size from paper.
c
No information regarding stage of treatment was provided by the authors.
d
1. Education: Facilitators varied by session and included a nurse, a social worker, dietician, physical therapist, image consultant, and physician.
e
The programme began as participants started chemotherapy and lasted throughout the treatment protocol (4‐6 months). A significant difference was identified between the conditions mid‐treatment but disappeared by
post‐treatment.
f
1. Education: Facilitators varied by session and included an endrinocologist, a minister, a psychologist, a nurse, and oncology social worker.
g
The 5‐week programme began as participants started radiotherapy. Outcome assessments were 2 and 6 months later.
6LEWIS‐SMITH ET AL.
information for adequate assessment. Sources of funding and poten-
tial conflicts of interest were also reviewed for the individual studies.
2.6 |Data synthesis
There were substantial clinical and methodological differences
between studies (e.g., in relation to study design, overall intervention
length and dose, and outcome measures), suggesting the likelihood
of high statistical heterogeneity if data were pooled.
46
This could con-
sequently produce misleading and nongeneralisable results in a meta‐
analysis. A meta‐analysis was therefore deemed inappropriate, and a
narrative synthesis was conducted instead.
47
3|RESULTS
The original search (January 2013) identified 17 papers that met inclu-
sion criteria, and the updated search (November 2017) identified 5
additional papers. Two of these papers were evaluating the same
intervention at different time points and are subsequently discussed
as one study.
22,23
One paper was an unpublished doctoral disserta-
tion.
43
Consequently, a total of 21 papers were included in the final
review and evaluated 26 interventions. Details concerning the format,
participants, and effect sizes of included interventions are displayed in
Table 1. Table 2 contains the outcome measures employed to assess
body image. Interventions that identified a significant improvement
at posttest only are referred to as “posttest effective interventions”
(n = 7), whilst interventions that demonstrated a delayed significant
improvement at follow‐up but not at post‐test are referred to as
“delayed‐effective interventions”(n = 2).
3.1 |Participant characteristics
The mean age of participants ranged from 43 to 61 years across the
studies, with a mean age of 51. With regard to the participants' stage
of treatment for breast cancer, 29% (n = 6) of studies included partic-
ipants who were still undergoing active treatment, whilst 48% (n = 10)
included participants who had completed active treatment. The
remaining studies (23%; n = 5) did not provide information regarding
participants' stage of treatment. The majority (n = 6; 67%) of the
posteffective or delayed‐effective interventions were delivered to
women who had finished active treatment. None of the studies
screened participants for elevated levels of poor body image.
3.2 |Intervention effects
There were no interventions with improvements at both post‐
intervention and follow‐up. However, 7 (27%) of the 26 interventions
demonstrated a significant improvement on at least one measure of
body image at posttest. Cohen's deffect sizes for posttest effective
interventions ranged from 0.15 to 1.43, with large effect sizes
reported in 3 (43%) of these. The effect size could not be calculated
for one intervention as the means and standard deviations were
absent.
26
When follow‐up was assessed in these studies, significant
effects at posttest were not sustained. Further, 2 interventions (8%
of all interventions) were not significant at posttest but demonstrated
improvements on body image at follow‐up. Indeed, one intervention
demonstrated a delayed large improvement (d= 1.40) at 2‐month fol-
low‐up,
24
whilst the other attained a small improvement (d= 0.23) 6
and half years later.
22,23
3.3 |Intervention characteristics
With regard to intervention approach, 31% (n = 8) of the 26 interven-
tions adopted a psychoeducational approach, 29% (n = 7) of interven-
tions adopted a physical‐activity‐based approach, 23% (n = 6) of
interventions adopted a psychotherapeutic approach, 4% (n = 1) of
interventions adopted a social‐support‐based approach, and 15%
(n = 4) of interventions combined different approaches. Only 2 (8%)
of the included interventions were reported to have been developed
using theory, and neither were effective. With regard to the nine
effective interventions, the majority adopted either a
psychoeducational (n = 3) or psychotherapeutic approach (n = 3).
Those with large effects employed psychotherapeutic approaches,
including Rational Emotive Behaviour Therapy
25
and Mindfulness‐
Based Stress Reduction (MBSR; including yoga;
28,29
). The only
delayed‐effective intervention with a large effect size employed a
psychoeducational approach.
24
The majority of the interventions (62%; n = 16), including those
which were effective (78%; n = 7), were delivered in person to a group
of participants. This also included 3 of the posttest effective
TABLE 2 Measures used to determine significant alterations of body
image
Questionnaire/scale used to measure Body Image
Measure Subscale
a
European Organisation for Research and
Treatment of Cancer ‐Quality of Life
Questionnaire Breast Cancer Module
(EORTC QLQ‐BR23; Sprangers et al 1996)
a1
Body Image
a2
Sadness due to
Hair Loss
b
Body Image Scale (Hopwood, Fletcher,
Lee, & Al Ghazal, 2001)
b1
Individual Body
Image
b2
Social Body
Image
c
Body Esteem Scale (Franzoi & Shields, 1984)
d
Body‐Image Scale (Berscheid, Walster, &
Bohrnstedt, 1972)
e
Cancer Rehabilitation Evaluation System
Questionnaire (CARES; Schag & Heinrich, 1990)
e1
Body Image
f
Body Image and Relationships Scale (Hormes
et al., 2008)
f1
Strength and
Health
f2
Social barriers
f3
Appearance and
Sexuality
g
Body‐Image Questionnaire (Bruchon‐Schweitzer,
1987)
h
Tennessee Self‐Concept Scale (Fitts, 1965)
h1
Physical Self
i
Visual Analogue Scale
j
Cancer Rehabilitation Evaluation System
Questionnaire—adapted by Authors (Helgeson
et al., 1999)
k
Self‐Concept Scale developed by authors (based
on previous research exploring psychosocial
outcomes associated with breast cancer
treatment; Scheier et al., 2005)
Note. To be used in conjunction with Table 1.
LEWIS‐SMITH ET AL.7
interventions with large effects.
25,28,29
The interventions ranged in
overall length between 14 minutes and 168 hours, with a mean length
of 24 hours and a mean number of 12 sessions. Whilst effective inter-
ventions were 34 hours in overall length and comprised of 18 ses-
sions, those with large effects were less than 20 hours in overall
length and were comprised of up to 8 sessions.
Facilitators differed in their profession across all of the interven-
tions; however, the majority had received formal training (77%;
n = 20) and half delivered the intervention alone (54%; n = 14). The
effective interventions also differed in these aspects; however, those
with large effects were delivered by a psychiatrist, a clinical psycholo-
gist, and the author of the paper, who had a nursing background.
3.4 |Components and content of the effective
interventions
The nine interventions demonstrating significant improvements on
body image at either postintervention or follow‐up adopted a variety
of different approaches and components (see S2 for a more detailed
overview of the components and content of the interventions). Two
interventions were based on physical activity. Mehnert and col-
leagues
27
evaluated a biweekly group exercise programme running
across a 10‐week period and led by a physiotherapist and sports ther-
apist. The activities included gymnastics, movement games, relaxation,
walking, jogging, and physiotherapeutic exercises. Speck and col-
leagues
31
evaluated a biweekly group strength training programme
led by a fitness instructor, comprised of “core”exercises to strengthen
abdominal and back muscles, followed by upper and lower body
weight‐lifting exercises (e.g., seated row, bicep curls, leg press, and
leg curl) with increasing resistance over the weeks.
Three interventions adopted a psychoeducational approach.
Hamzehgardeshi and colleagues
26
evaluated a 6‐session group
counselling intervention led by a midwife, comprising of lectures and
group discussions. Content included identifying and managing
stressors and symptoms, managing changes to the body and sexuality,
and improving body image. There was also homework between ses-
sions. The other 2 interventions were delivered on an individual basis.
Salonen and colleagues
30
evaluated a telephone support intervention,
within which participants received a one‐off call from a physiothera-
pist 1 week following surgery. Content was based on Sluijs' themes
from patient education in physical therapy,
48
such as providing
instructions for home exercises, counselling on stress‐related prob-
lems, and exploring patients' demands and expectations. Hsu and col-
leagues
24
evaluated a 2‐session intervention, whereby the first session
was delivered before surgery, and the second was delivered after
surgery. The first session provided information and support on the
disease, surgery and aftercare, and expected appearance changes.
The second session addressed sourcing and wearing a breast prosthe-
sis and reconstructing confidence in appearance.
Three effective interventions adopted a psychotherapeutic
approach. The first was a group Rational Emotive Behaviour Ther-
apy‐based programme; a form of cognitive behavioural therapy
(CBT;
25
). The 6‐session programme was delivered by a psychiatrist,
and content included logical treatment (reducing irrational and illog-
ical beliefs in favour of rational and logical beliefs), muscle
relaxation training, adaptive skills, and problem solving, and partici-
pants completed homework between sessions. The other 2 group
interventions were MBSR programmes and followed a very similar
format. The eight‐session group programmes incorporated medita-
tion, body scans, yoga exercises, identifying reactions to stress,
and awareness of events on feelings, thoughts, and bodily sensa-
tions.
28,29
The final intervention was a group 1‐week multimodal
residential programme,
22,23
delivered by a range of professionals.
Participants were provided with information and support to help
manage the physical, psychological, and economic consequences
of the disease. The theoretical‐educational lectures were mixed
with physical activities, dance therapy, relaxation, and social
activities.
3.5 |Outcome measures
With regard to the outcome measures employed to evaluate changes
in body image, the majority of studies (n = 15; 71%) employed cancer‐
specific scales, as opposed to scales that measured aspects of body
image and well being nonspecific to cancer and related treatment.
The most commonly employed scales were the Body Image subscale
of the European Organisation for Research and Treatment of Cancer
Quality of Life Questionnaire –Breast Cancer Module (EORTC QLQ‐
BR23; n = 4;)
49
and the Body Image Scale (BIS; n = 4;).
50
Nearly all
effective interventions employed breast‐cancer specific scales (n = 8;
89%), with larger effect sizes generally attained in studies employing
the BIS (ds = 0.69‐1.43). Aspects of body image that were improved
included dissatisfaction with appearance and scarring, the avoidance
of circumstances which provoke concern about appearance, and feel-
ings of defeminisation and of the body feeling less “whole”after
treatment.
3.6 |Methodological quality
Table 3 summarises the results of the risk of bias evaluation of all 21
studies. Whilst the majority of studies (71%; n = 15) conducted ran-
dom sequence generation, only half of these explicitly described their
methods, with even less ensuring allocation concealment. Nearly all
studies (90%; n = 19) indicated a high risk of performance and detec-
tion bias. However, these biases are often very difficult to eliminate in
psychosocial and behavioural interventions. Half of the studies (57%;
n = 12) adequately described the rates of attrition and reasons for
exclusion, consequently suggesting a low risk of attrition bias. Most
studies (86%; n = 18) reported prespecified outcomes consistently
throughout, thus indicating a low risk of reporting bias. Further, it
was deemed that there was a low risk of other sources of bias (90%;
n = 19). Only 33% (n = 7;
22-24,26,29,34,36,41
) of the evaluative studies
indicated having conducted a power analysis. Of these, 57%
(n = 4;
24,26,36,41
) were powered to detect effects of at least medium
effect size. Finally, the majority of the studies reported their sources
of funding (71%; n = 15), with none suggesting a potential conflict of
interest (see S3 for further details). Among the studies which explicitly
referred to any conflicts of interest (43%; n = 9), only one study indi-
cated a financial interest.
41
8LEWIS‐SMITH ET AL.
4|DISCUSSION
We conducted a systematic review of interventions delivered to
women who have undergone treatment for breast cancer, with the
purpose of identifying interventions effective in improving body
image. The number of interventions identified (n = 26) was encourag-
ing; however, those that reported significant improvements on body
image at postintervention or follow‐up was limited (35%; n = 9). These
findings indicate the necessity for further research in this field, which
could be informed by the small number of existing interventions that
have demonstrated improvements in body image among this group.
Whilst a wide variety of approaches were adopted across effec-
tive interventions, this review highlights the absence of theoretically
driven interventions in this area. None of the intervention evaluation
papers explicitly stated whether their interventions were theoretically
informed, and of the minority that did discuss theory, it was not clearly
articulated as to how the theory contributed to intervention develop-
ment or the research evaluation design. Further, only one evaluative
paper hypothesised and tested mechanisms of change for their inter-
vention. Indeed, Speck and colleagues
31
proposed that their weight
training programme would improve body image due to increased
muscle strength and that this in turn would increase functional ability,
which is important to one's body image. However, tests of mediation
were nonsignificant, and the mechanisms of action consequently
remain unclear. A further concern relates to the lack of clarity with
regard to whether interventions were primarily targeting body image.
As highlighted in Table S2, interventions tended to employ multiple
aims, and only a minority reported their primary and secondary
targeted outcomes. In future, it would be helpful for studies to clearly
specify the intervention targets and outcome measures as primary and
secondary so that the intervention effects on body image can be bet-
ter interpreted in the context of the interventions' aims and nature.
Nonetheless, there was greater consistency regarding format and
delivery. Effective interventions were generally delivered face to face
to groups of women, a format which has been argued to foster group
cohesion. It enables members to feel accepted and supported, which
has been considered a “necessary precondition for other therapeutic
factors to function optimally”
51
: (p.49). A further benefit is the lower
cost of delivery compared with those provided on an individual basis.
The majority of effective interventions only had one trained facilitator,
which not only lowers costs, but also eliminates potential for compe-
tition between coleaders.
52
There was disparity between effective interventions concerning
the stage of treatment of participants. Interventions adopting a phys-
ical‐activity‐based approach tended to be delivered to women who
had finished active treatment, as opposed to those who were still
undergoing surgery, chemotherapy, and radiotherapy. This may be
because of the latter lacking the physical capability to engage in
TABLE 3 Judgement regarding risk of bias of according to the Cochrane Collaboration risk of bias tool
Random Sequence
Generation
Allocation
Concealment
Blinding:
Participants
Blinding:
Facilitators
Blinding:
Outcome
Assessors
Incomplete
Outcome Data
Selective
Reporting
Other
Bias
Interventions with significant improvements on body image at follow‐up only and not at postintervention
Björneklett et al (2013, 2012)
22,23
++−−?−++
Hsu et al (2010)
24
−−−−?+ ++
Interventions with significant improvements on body image at postintervention only
Fadaei et al (2011)
25
−−−−?? ++
Hamzehgardeshi et al (2017)
26
+?−−?+ −−
Mehnert et al (2011)
27
++−−?+ ++
Pintado and Andrade (2017)
28
−−+−?+ ++
Rahmani and Talepasand (2015)
29
+?−−?+ ++
Salonen et al (2009)
30
−−−−?−++
Speck et al (2010)
31
++−−+−++
Interventions with no significant improvements on body image
Beatty et al (2010)
32
+ + + N/A ? + + +
Dibbell‐Hope (2000)
33
+?−−?? ++
Duijts et al (2012)
34
+?−−?+ −+
Helgeson et al (1999)
35
+?−−?? −+
Jun et al (2011)
36
+−−−?+ ++
Mock et al (1994)
37
−−−−?−++
Pinto et al (2005)
38
+?−−?+ ++
Quintard and Lakdja (2008)
39
+?−−?+ ++
Sandel et al (2005)
40
++−−?+ ++
Scheier et al (2005)
41
+?−−?−++
Svensk et al (2009)
42
+?−−?+ ++
Vito (2007)
43
−−−−?−+−
Note. Plus sign (+) represents quality criteria satisfied and low risk of bias; negative sign (−) represents quality criteria not satisfied and high risk of bias;
question mark (?) represents insufficient information in the paper to judge risk of bias; N/A, not applicable.
LEWIS‐SMITH ET AL.9
physical activity. Nonetheless, these findings indicate that support for
body image can be beneficial at any stage of treatment and different
approaches can accommodate different stages of treatment and asso-
ciated capabilities.
However, the degree of confidence in these effective interventions
and their associated characteristics is determined by the methodologi-
cal rigour of their evaluative studies. It was therefore disappointing that
the 3 interventions reporting the largest effect sizes indicated a high risk
of bias overall. Confidence can, however, be placed in the 4 interven-
tions that were evaluated in studies considered to be of sound method-
ological quality overall.
22,23,27,29,31
These interventions include a
multimodal residential programme, a multiactivity exercise programme,
a strength training programme, and a MBSR programme. This review
therefore suggests that they should be prioritised and recommended
to health professionals aiming to improve body image among women
who have undergone treatment for breast cancer.
4.1 |Recommendations for practice and future
research
Impaired body image is an issue of growing importance among women
undergoing or following treatment for breast cancer, emphasising the
need for interventions. Findings from this review indicate that prog-
ress is being made in this area. Nonetheless, to advance developments
in this area strategically, we propose several recommendations for
practitioners and researchers based on the findings of this review.
First, we recommend the use of empirically supported theory in
the development and evaluation of interventions. Theory can help
inform targets for intervention (i.e., mechanisms of action), which
theoretically, if changed, will lead to changes in the outcome of
interest (i.e., body image).
53
Consequently, interventions that draw
on theory may have stronger effects than those that do not.
54-56
The lack of theoretical basis reported for interventions in the present
review limits understanding of mechanisms by which the effective
interventions improved body image, and may also have contributed
toward the absence of maintained improvements.
Second, we recommend the adoption of an approach which
explicitly and exclusively addresses body image, as this focus was
associated with improvements in the evaluative studies examined.
An explicit focus on body image validates women's concerns, many
of whom feel that health professionals fail to recognise the adverse
impacts of treatment‐related appearance changes.
57
Relatedly, future
research could usefully investigate the impact of interventions on
body image related to temporary and permanent appearance changes.
Further, whilst physical‐activity‐based interventions in this review
indicate promise, previous meta‐analyses and systematic reviews eval-
uating psychosocial interventions on a range of psychosocial out-
comes among both women treated for breast cancer and the wider
population suggest that a psychotherapeutic intervention may attain
longer‐lasting improvements in body image.
58-60
Such an approach
may also better accommodate women at different stages of active
treatment, who will vary with regard to their physical ability. Physical
activity may even be harmful, as demonstrated by previous evaluative
studies with women both during, and following, active treatment.
61,62
Third, we recommend that psychotherapeutic interventions move
beyond a narrow disease‐focused approach. Psychotherapeutic inter-
ventions in the present review tend to reduce a patient to their illness
and fail to recognise the broader aspects of their lives that may influence
their health and wellbeing. Indeed, they focus on concerns relating to
disease and treatment (e.g., aftercare of surgery and managing appear-
ance changes), in place of a more holistic theoretical approach targeting
broader and modifiable sociocultural and psychological influences on
body image. The absence of maintained improvements on body image
may be related to the narrow approach adopted by the interventions.
In contrast, considering the interaction between the individual, the dis-
ease, and the wider sociocultural context may help to inform the devel-
opment of effective interventions and their underlying mechanisms of
change. For example, a systematic review of interventions conducted
among women in midlife more broadly
63
found that a CBT‐based inter-
vention targeting broad modifiable influences (e.g., appearance impor-
tance and perceived media pressure to alter appearance) had both the
largest and longest‐lasting improvements on body image.
64
These
sociocultural and psychological factors have also been found to influ-
ence the body image of women treated for breast cancer,
65,66
thus indi-
cating the potential utility of this holistic CBT‐based intervention to
improve body image among this subgroup of women in midlife.
Fourth, future studies would benefit from employing follow‐up
evaluations. Only nine (43%) of all studies in the present review con-
ducted a follow‐up evaluation of the intervention, and only half of these
included a follow‐up point of at least 6 months, which is consistent with
the Society of Prevention Research criteria for efficacy.
67
The majority
of the effective interventions assessed post‐test improvements only,
precluding conclusions concerning sustained effects. We therefore rec-
ommend that follow‐up assessments are conducted in future studies,
especially given that benefits can be delayed, as demonstrated by two
of the effective interventions. This is particularly important, as alter-
ations to appearance, and consequently associated body image, are
likely to vary depending on the stage of treatment, thus influencing
the timing of the intervention's effects. Further, consistency in the time
points across studies would facilitate comparisons of maintained inter-
vention effects and consideration of the costs to deliver these interven-
tions in relation to the results attained.
Fifth, we recommend that evaluative studies employ stricter
methodology, in order to increase levels of confidence in their find-
ings. Future studies would benefit from ensuring randomisation of
participants and allocation concealment, as trials employing inade-
quate or unclear concealment tend to exaggerate treatment
effects.
68,69
We also urge researchers to explicitly report, and address
reasons for, attrition. This would help health professionals determine
whether these interventions are likely to be appropriate and accept-
able to their clients. Finally, the likelihood of performance and detec-
tion bias would be reduced if independent and external facilitators
and outcome assessors were sought, and centralised randomisation
procedures were pursued.
4.2 |Study limitations
A potential drawback of the review is the exclusion of papers that
include samples of women with a mean age below 35 years. Whilst
10 LEWIS‐SMITH ET AL.
we acknowledge that this group of women are also likely to experi-
ence body image concerns, we sought to identify papers comprised
of women who represent the age of the majority of breast cancer
cases. Further, the majority of studies tend to define “younger
women”with breast cancer as below 50 years of age.
70
Additionally,
the exclusion of studies without a control group may have increased
the risk of publication bias. However, the comprehensive search pro-
cedure, which included the consideration of grey literature, may have
limited the potential impact of this bias,
71
as studies which do not
show effective results take longer to be published or are not published
at all.
72
Finally, the importance of conducting power analyses has been
previously emphasised,
73
yet the majority of included studies threat-
ened internal validity by failing to describe how their sample size
was ascertained. Most evaluative studies were comprised of small
sample sizes and were therefore likely to have lacked the power to
detect intervention effects. This suggests that some of the nonsignif-
icant interventions identified in the present review may have been
due to lack of statistical power. This highlights the importance of
future research to report power analyses.
4.3 |Clinical implications and conclusions
This review has identified nine interventions that have improved body
image among women at different stages of treatment for breast
cancer, at either postintervention or follow‐up assessment. Effective
interventions were comprised of an array of physical‐activity‐based,
psychoeducational, and psychotherapeutic approaches, and the four
interventions that were evaluated within methodologically sound
studies were delivered to groups across multiple sessions. These
interventions are therefore recommended for use by health profes-
sionals.
26,27,33-36
However, the absence of maintained improvements
on body image within the included studies highlights the potential
benefits of drawing upon theory to inform intervention development
and evaluation and targeting broader non–disease‐specific modifiable
influences. These findings also indicate the need for future research
to employ evaluative methodology of greater rigour, in order to instil
increased levels of confidence in reports of effective interventions.
ACKNOWLEDGEMENTS
This work was supported by doctoral funding provided by the Univer-
sity of the West of England to the first author.
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
ORCID
Helena Lewis‐Smith http://orcid.org/0000-0001-9000-8142
REFERENCES
1. Falk Dahl CA, Reinertsen KV, Nesvold IL, Fosså SD, Dahl AA. A study
of body image in long‐term breast cancer survivors. Cancer.
2010;116(15):3549‐3557.
2. Lam WWT, Li WWY, Bonanno GA, et al. Trajectories of body image
and sexuality during the first year following diagnosis of breast cancer
and their relationship to 6 years psychosocial outcomes. Breast Cancer
Res Treat. 2012;131(3):957‐967.
3. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortal-
ity worldwide: sources, methods and major patterns in GLOBOCAN
2012. Int J Cancer. 2015;136(5):E359‐E386.
4. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin.
2016;66(1):7‐30.
5. American Cancer Society. Cancer facts & figures 2017 [cited 2017 15
Nov]. Available from https://www.cancer.org/research/cancer‐facts‐
statistics/all‐cancer‐facts‐figures.html
6. Office of National Statistics. Cancer survival in England: adult, stage at
diagnosis and childhood—patients followed up to 2016 [cited 2017 15
Nov]. Available from https://www.ons.gov.uk/peoplepopulation
andcommunity/healthandsocialcare/conditionsanddiseases/cancersur
vivalinengland
7. Sheppard LA, Ely S. Breast cancer and sexuality. Breast J.
2008;14(2):176‐181.
8. Lemieux J, Maunsell E, Provencher L. Chemotherapy‐induced alopecia
and effects on quality of life among women with breast cancer: a liter-
ature review. Psychooncology. 2008;17(4):317‐328.
9. Begovic‐Juhant A, Chmielewski A, Iwuagwu S, Chapman LA. Impact of
body image on depression and quality of life among women with
breast cancer. J Psychosoc Oncol. 2012;30(4):446‐460.
10. Parker PA, Youssef A, Walker S, et al. Short‐term and long‐term psy-
chosocial adjustment and quality of life in women undergoing
different surgical procedures for breast cancer. Ann Surg Oncol.
2007;14(11):3078‐3089.
11. Cousson‐Gelie F, Bruchon‐Schweitzer M, Dilhuydy JM, Jutand M‐A.
Do anxiety, body image, social support and coping strategies predict
survival in breast cancer? A ten‐year follow‐up study. Psychosomatics.
2007;48(3):211‐216.
12. Centers for Disease Control and Prevention & Lance Armstrong Foun-
dation. A national action plan for cancer survivorship: advancing public
health strategies. [cited 2016 24 Jan]. Available from https://www.cdc.
gov/cancer/survivorship/pdf/plan.pdf
13. Department of Health, Macmillan Cancer Support, & NHS Improve-
ment. Living with & beyond cancer: taking action to improve
outcomes (an update to the 2010 The National Cancer Survivorship
Initiative Vision). [cited 2016 24 Jan]. Available from https://www.
gov.uk/government/uploads/system/uploads/attachment_data/file/
181054/9333‐TSO‐2900664‐NCSI_Report_FINAL.pdf
14. Breast Cancer Care. My body, myself: altered body image, intimacy
and sex after breast cancer. [cited 2016 20 Jan]. Available from
https://www.breastcancercare.org.uk/sites/default/files/files/my‐
body‐myself‐report.pdf
15. Fingeret MC, Teo I, Epner DE. Managing body image difficulties of
adult cancer patients: lessons from available research. Cancer.
2014;120(5):633‐641.
16. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0 [updated March 2011]. Chichester: Wiley;
2011.
17. Han W, Kim SW, Park IA, et al. Young age: an independent risk factor
for disease‐free survival in women with operable breast cancer. BMC
Cancer. 2004;4(1):82.
18. Cancer Research UK. Breast cancer (C50), average number of new
cases per year and age‐specific incidence rates, females, UK, 2010‐
2012 [cited 2017 15 Nov]. Available from http://www.
cancerresearchuk.org/health‐professional/cancer‐statistics/statistics‐
by‐cancer‐type/breast‐cancer
19. Grogan S. Body Image: Understanding Body Dissatisfaction in Men,
Women and Children. London: Routledge; 2008.
20. Shadish WR, Cook TD, Campbell DT. Experimental and Quasi‐Experi-
mental Designs for Generalized Causal Inference. Boston MA:
Houghton Mifflin Company; 2002.
21. Bottomley A. To randomise or not to randomise: methodological
pitfalls of the RCT design in psychosocial intervention studies. Eur J
Cancer Care. 1997;6(3):222‐230.
LEWIS‐SMITH ET AL.11
22. Björneklett HG, Lindemalm C, Ojutkangas M‐L, et al. A randomized
controlled trial of a support group intervention on the quality of life
and fatigue in women after primary treatment for early breast cancer.
Support Care Cancer. 2012;20(12):3325‐3334.
23. Björneklett HG, Rosenblad A, Lindemalm C, et al. Long‐term follow‐up
of a randomized study of support group intervention in women with
primary breast cancer. J Psychosom Res. 2013;74(4):346‐353.
24. Hsu S‐C, Wang H‐H, Chu S‐Y, Yen H‐F. Effectiveness of informational
and emotional consultation on the psychological impact on women
with breast cancer who underwent modified radical mastectomy.
J Nurs Res. 2010;18(3):215‐226.
25. Fadaei S, Janighorban M, Mehrabi T, Ahmadi SA, Mokaryan F,
Gukizade A. Effects of cognitive behavioral counseling on body Image
following mastectomy. J Res Med Sci. 2011;16(8):1047‐1054.
26. Hamzehgardeshi Z, Moosazadeh M, Elyasi F, et al. Effect of midwifery‐
based counseling support program on body image of breast cancer
women survivors. Asian Pac J Cancer Prev. 2017;18(5):1293‐1299.
27. Mehnert A, Veers S, Howaldt D, Braumann K‐M, Koch U, Schulz K‐H.
Effects of a physical exercise rehabilitation group program on anxiety,
depression, body image, and health‐related quality of life among breast
cancer patients. Oncol Res Treat. 2011;34(5):248‐253.
28. Pintado S, Andrade S. Randomized controlled trial of mindfulness pro-
gram to enhance body image in patients with breast cancer. Eur J Integr
Med. 2017;12:147‐152.
29. Rahmani S, Talepasand S. The effect of group Mindfulness‐Based
Stress Reduction program and conscious yoga on the fatigue severity
and global and specific life quality in women with breast cancer. Med
J Islam Repub Iran. 2015;29:175.
30. Salonen P, Tarkka M‐T, Kellokumpu‐Lehtinen P‐L, Åstedt‐Kurki P,
Luukkaala T, Kaunonen M. Telephone intervention and quality of life
in patients with breast cancer. Cancer Nurs. 2009;32(3):177‐190.
31. Speck RM, Gross CR, Hormes JM, et al. Changes in the body image and
relationship scale following a one‐year strength training trial for breast
cancer survivors with or at risk for lymphedema. Breast Cancer Res
Treat. 2010;121(2):421‐430.
32. Beatty LJ, Koczwara B, Rice J, Wade TD. A randomised controlled trial
to evaluate the effects of a self‐help workbook intervention on dis-
tress, coping and quality of life after breast cancer diagnosis. Med J
Aust. 2010;193(5):S68.
33. Dibbell‐Hope S. The use of dance/movement therapy in psychological
adaptation to breast cancer. Arts Psychother. 2000;27(1):51‐68.
34. Duijts SFA, van Beurden M, Oldenburg HSA, et al. Efficacy of cognitive
behavioral therapy and physical exercise in alleviating treatment‐
induced menopausal symptoms in patients with breast cancer: results
of a randomized, controlled, multicenter trial. J Clin Oncol.
2012;30(33):4124‐4133.
35. Helgeson VS, Cohen S, Schulz R, Yasko J. Education and peer discus-
sion group interventions and adjustment to breast cancer. Arch Gen
Psychiatry. 1999;56(4):340‐347.
36. Jun E‐Y, Kim S, Chang S‐B, Oh K, Kang HS, Kang SS. The effect of a
sexual life reframing program on marital intimacy, body image, and
sexual function among breast cancer survivors. Cancer Nurs.
2011;34(2):142‐149.
37. Mock V, Burke MB, Sheehan P, et al. A nursing rehabilitation program
for women with breast cancer receiving adjuvant chemotherapy. Oncol
Nurs Forum. 1994;21(5):899‐907.
38. Pinto BM, Frierson GM, Rabin C, Trunzo JJ, Marcus BH. Home‐based
physical activity intervention for breast cancer patients. J Clin Oncol.
2005;23(15):3577‐3587.
39. Quintard B, Lakdja F. Assessing the effect of beauty treatments on
psychological distress, body image, and coping: a longitudinal study
of patients undergoing surgical procedures for breast cancer.
Psychooncology. 2008;17(10):1032‐1038.
40. Sandel SL, Judge JO, Landry N, Faria L, Ouellette R, Majczak M. Dance
and movement program improves quality‐of‐life measures in breast
cancer survivors. Cancer Nurs. 2005;28(4):301‐309.
41. Scheier MF, Helgeson VS, Schulz R, et al. Interventions to enhance
physical and psychological functioning among younger women who
are ending nonhormonal adjuvant treatment for early‐stage breast
cancer. J Clin Oncol. 2005;23(19):4298‐4311.
42. Svensk A, Öster I, Thyme K, et al. Art therapy improves experienced
quality of life among women undergoing treatment for breast cancer:
a randomized controlled study. Eur J Cancer Care. 2009;18(1):69‐77.
43. Vito NL. The Effects of a Yoga Intervention on Physical and Psychological
Functioning for Breast Cancer Survivors. ProQuest; 2007.
44. Rosnow RL, Rosenthal R. Computing contrasts, effect sizes, and
counternulls on other people's published data: general procedures for
research consumers. Psychol Methods. 1996;1(4):331‐340.
45. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed.
Hillsdale NJ: Erlbaum; 1988.
46. Lau J, Ioannidis JP, Schmid CH. Summing up evidence: one answer is
not always enough. Lancet. 1998;351(9096):123‐127.
47. Ryan R. Heterogeneity and subgroup analyses in Cochran Consumers
and Communication Review Group reviews: planning the analysis at
protocol stage [cited 2015 16 Jan]. Available from: http://ccrg.
cohrane.org.
48. Sluijs EM. Patient Education in Physical Therapy. NIVEL: Utrecht, The
Netherlands; 1991.
49. Sprangers MA, Groenvold M, Arraras JI, et al. The European Organiza-
tion for Research and Treatment of Cancer breast cancer‐specific
quality‐of‐life questionnaire module: first results from a three‐country
field study. J Clin Oncol. 1996;14(10):2756‐2768.
50. Hopwood P, Fletcher I, Lee A, Al Ghazal S. A body image scale for use
with cancer patients. Eur J Cancer. 2001;37(2):189‐197.
51. Yalom ID. The Theory and Practice of Group Psychotherapy. 4th ed. New
York: Basic Books; 1995.
52. Roller B, Nelson V. Cotherapy. In: Kaplan HI, Sadock BJ, eds. Compre-
hensive Group Psychotherapy. Baltimore, MD: Williams & Williams;
1993.
53. Hardeman W, Sutton S, Griffin S, et al. A causal modelling approach to
the development of theory‐based behaviour change programmes for
trial evaluation. Health Educ Res. 2005;20(6):676‐687.
54. Glanz K, Bishop DB. The role of behavioral science theory in develop-
ment and implementation of public health interventions. Annu Rev
Public Health. 2010;31(1):399‐418.
55. Webb T, Joseph J, Yardley L, Michie S. Using the internet to promote
health behavior change: a systematic review and meta‐analysis of the
impact of theoretical basis, use of behavior change techniques, and
mode of delivery on efficacy. J Med Internet Res. 2010;12(1):e4.
56. Michie S, Abraham C. Interventions to change health behaviours: evi-
dence‐based or evidence‐inspired? Psychol Health. 2004;19(1):29‐49.
57. McWilliam CL, Brown JB, Stewart M. Breast cancer patients' experi-
ences of patient–doctor communication: a working relationship.
Patient Educ Couns. 2000;39(2):191‐204.
58. Jarry JL, Ip K. The effectiveness of stand‐alone cognitive‐behavioural
therapy for body image: A meta‐analysis. Body Image.
2005;2(4):317‐331.
59. McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR,
Courneya KS. Effects of exercise on breast cancer patients and survi-
vors: a systematic review and meta‐analysis. Can Med Assoc J.
2006;175(1):34‐41.
60. Tatrow K, Montgomery GH. Cognitive behavioral therapy techniques
for distress and pain in breast cancer patients: a meta‐analysis. J Behav
Med. 2006;29(1):17‐27.
61. Campbell A, Mutrie N, White F, McGuire F, Kearney N. A pilot study of
a supervised group exercise programme as a rehabilitation treatment
12 LEWIS‐SMITH ET AL.
for women with breast cancer receiving adjuvant treatment. Eur J
Oncol Nurs. 2005;9(1):56‐63.
62. Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS. Ran-
domized controlled trial of exercise training in postmenopausal breast
cancer survivors: cardiopulmonary and quality of life outcomes. J Clin
Oncol. 2003;21(9):1660‐1668.
63. Lewis‐Smith H, Diedrichs PC, Rumsey N, Harcourt D. A systematic
review of interventions on body image and disordered eating out-
comes among women in midlife. Int J Eat Disord. 2016;49(1):5‐18.
64. McLean SA, Paxton SJ, Wertheim EH. A body image and disordered
eating intervention for women in midlife: a randomized controlled trial.
J Consult Clin Psychol. 2011;79(6):751‐758.
65. Moreira H, Canavarro MC. A longitudinal study about the body image
and psychosocial adjustment of breast cancer patients during the
course of the disease. Eur J Oncol Nurs. 2010;14(4):263‐270.
66. Przezdziecki A, Sherman KA, Baillie A, Taylor A, Foley E, Stalgis‐Bilinski
K. My changed body: breast cancer, body image, distress and self‐com-
passion. Psychooncology. 2013;22(8):1872‐1879.
67. Flay BR, Biglan A, Boruch RF, et al. Standards of evidence: Criteria for
efficacy, effectiveness and dissemination. Prev Sci. 2005;6(3):151‐175.
68. Jüni P, Altman DG, Egger M. Assessing the quality of controlled clinical
trials. BMJ. 2001;323(7303):42‐46.
69. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of
bias: dimensions of methodological quality associated with estimates
of treatment effects in controlled trials. JAMA. 1995;273(5):408‐412.
70. Paterson CL, Lengacher CA, Donovan KA, Kip KE, Tofthagen CS. Body
image in younger breast cancer survivors: a systematic review. Cancer
Nurs. 2016;39(1):E39‐E58.
71. Conn VS, Isaramalai S, Rath S, Jantarakupt P, Wadhawan R, Dash Y.
Beyond MEDLINE for literature searches. J Nurs Scholarsh.
2003;35(2):177‐182.
72. Ioannidis JP. Effect of the statistical significance of results on the time
to completion and publication of randomized efficacy trials. JAMA.
1998;279(4):281‐286.
73. Charles P, Giraudeau B, Dechartres A, Baron G, Ravaud P. Reporting of
sample size calculation in randomised controlled trials: review. BMJ.
2009;338(may12 1):b1732.
SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
How to cite this article: Lewis‐Smith H, Diedrichs PC,
Rumsey N, Harcourt D. Efficacy of psychosocial and physical
activity‐based interventions to improve body image among
women treated for breast cancer: A systematic review. Psy-
cho‐Oncology. 2018;1–13. https://doi.org/10.1002/pon.4870
LEWIS‐SMITH ET AL.13
