Breast cancer is the second most common type of cancer in the United States, and greater than 89% of those diagnosed with breast cancer are surviving at least 5 years after diagnosis.1 In terms of younger women diagnosed with breast cancer, there is a growing number of younger women diagnosed, with an estimate of 33.6% of new cases per year in women 54 years or younger.1 In addition to physical and psychological problems related to treatment, these women often face problems related to sexuality, including body image and related distress for this problem. Body image concerns in younger women have been attributed to loss of the breast from surgery, resulting scarring, and physical changes resulting from adjuvant treatment, all of which can have an impact on overall quality of life and, in particular, body image perceptions in younger women.2
Body image has been referred to as the picture of our own body that we form in our mind, and associated characteristics include expression of emotions, imitation, identification, beauty, and social aspects.3 This construct in the context of breast cancer is multidimensional. Hopwood et al4 identified 3 areas that are characteristics of the complex concept of body image in women who have been treated for breast cancer. These include the affective (feeling feminine, feeling attractive), behavioral (avoiding people because of appearance), and cognitive (satisfaction with appearance or with scar). Han et al5 defined body image after breast cancer to include the characteristics of the mental image of one’s body, attitude about appearance and state of health, and sexual functioning. The theoretical framework developed by Fingeret et al6 is specific to body image in women with breast cancer undergoing reconstruction and includes facets of perception, cognition, behavior, and emotion, as they relate to the function of the body after diagnosis and treatment for breast cancer.
Women with better conceptualization of their body image have been found to cope better with cancer.5 Poor body image perceptions have the potential to negatively impact the physical and psychological functioning of the breast cancer survivor and also the well-being of their partnered relationships.7 Poorer body image has been linked to greater overall psychological distress in the breast cancer patient8 and was previously found to be associated with greater depression and poorer quality of life.9
Younger women are often treated for more aggressive breast cancers, requiring more radical surgeries, as well as adjuvant treatments such as chemotherapy and radiation.10 In the study by Kissane et al,11 the researchers found that advanced-stage breast cancer patients were more dissatisfied with their body image when compared with early-stage breast cancer patients. Younger women with breast cancer receiving mastectomy and reconstruction as treatment for breast cancer, which is a more prevalent treatment in the younger population, also report a more negative body image than do those receiving breast-conserving surgery, such as a lumpectomy, immediately following treatment.12,13 Treatment with chemotherapy often results in hair loss, weight gain, and abrupt onset of menopausal symptoms, which are particularly distressing to younger women.14–16
In terms of physical functioning, a negative body image perception has often been found to be associated with greater sexual difficulties.17 These difficulties can include hot flashes, vaginal dryness, atrophic vaginitis, and decreased libido, as a result of premature menopause, which can have a particularly negative effect on the sexuality of the younger woman being treated for breast cancer.18,19 Women less satisfied with their body image after breast cancer diagnosis are up to 2.5 times more likely to experience sexual functioning issues, which establishes the importance of addressing both of these topics concurrently.17 Limiting the focus of sexuality after treatment for breast cancer to sexual functioning alone, as has been the trend in research to date, does not address psychological aspects of sexuality, such as perceptions of body image.20 Although related, body image and sexuality are 2 distinct concepts that can influence the quality of life of the breast cancer survivor. It has been established that sexuality is an integral part of the overall wellness of an individual, and body image perception is a key component of sexual health.21
Adjustments to treatment sequelae can also have an impact on both partner and breast cancer patient, producing physical limitations and negatively impacting body image and sexual functioning in the patient22,23 and higher levels of psychological distress in partners of breast cancer patients.24 Greater partner emotional support has been found to be associated with fewer sexual difficulties after treatment among breast cancer survivors,25 and although the literature is scarce related to body image and partnered relationships, 1 study did find that breast cancer patients who perceived a more positive partnered relationship were more likely to experience better body image.26
There are limited data examining the potential impact of problems related to body image, which may also affect the quality of life of breast cancer survivors. There is the potential for these problems to have the greatest impact on younger women,12,13,19,27 a group that is of increasingly greater proportion in the long-term cancer survivor population.28 The objectives of this systematic review are to synthesize the current knowledge related to body image, with particular attention paid to the impact of body image disturbance and related distress in younger breast cancer survivors, and to provide directions for future research in this important survivorship area.
A comprehensive review of the literature was conducted to synthesize evidence in the literature for body image in younger breast cancer survivors, a group particularly at risk for body image issues after treatment.12,13,19,27 The terms “body image,” “sexuality intervention,” “women,” “younger women,” and “breast cancer” were searched in the PubMed, PsycINFO, CINAHL, Web of Knowledge, and Science Direct databases from January 2000 through January 2014. The review included articles published starting in the year 2000 in order to establish the current state of the science related to this topic, a key component of which is including those studies that were most recent and examined women treated with the most current treatment modalities. It was not expected that studies published prior to 2000 would provide any further depth to this synthesis of literature. Because of restricted results when focusing only on literature examining younger breast cancer survivors, and finding only 15 relevant articles, the inclusion criteria were expanded to include all publications that measured body image as an outcome variable in breast cancer survivors and that reported significant outcomes related to age in the survivors. This provided the opportunity for the comparative assessment of younger versus older women with respect to body image, providing valuable information about this concept in the context of age. For the purposes of this review, “younger women” was subjective based on each study included and for those studies not restricted to only younger women, this was defined as any comparison by age with results reported in the article. Inclusion criteria for this review were as follows: (1) original research, (2) published in English, (3) measuring body image as a primary outcome variable, and (4) results included reporting of age-related outcomes. Articles that were excluded were the following: (1) dissertations, (2) nonresearch articles, (3) articles that did not measure the concept of body image as a primary outcome variable, (4) meeting abstracts, and (5) articles published prior to 2000. The rationale for this inclusion and exclusion criteria stems from the intent of this systematic review to identify issues related to body image disturbance in younger versus older breast cancer survivors, but also to elucidate from this published literature any other areas of distress that younger women are experiencing as treatment for breast cancer ends and the survivorship period begins.
Data were extracted from the articles that met inclusion criteria and placed into a summary table (Table). Author C.L.P. performed the data extraction process independently. The data in the Table are arranged chronologically and then alphabetically by year. The purpose, country of origin, sample size, sample characteristics, study design, study methods, key findings, and limitations from each study were documented in this table for further analysis.
A total of 401 potential abstracts were identified for inclusion in this review of the literature (Figure). There were 44 studies retrieved from PubMed, 22 from CINAHL, 20 from OVID/PsycINFO, 72 from Web of Knowledge, and 243 from the Science Direct databases. Of these results, 318 were eliminated upon initial abstract review, 245 because they did not meet inclusion criteria and 73 because they were duplicate articles. With 83 articles retrieved for further evaluation, 47 of these were excluded upon article review because they were a review article (1), not breast cancer (2), did not include a measure of body image (8), did not include body image as a primary outcome variable (5), older women only in the study population (2), the study was testing optimal intervention timing (1), the study did not report age-related outcomes (22), or the articles were published prior to 2000 (6). Therefore, the final analysis includes 36 articles that met the inclusion criteria for the purposes of this review (Table). Pertinent findings from this synthesis are presented in an integrated manner as they relate to body image in younger women. This first includes a breakdown of the various types of study designs, study countries of origin, and measurement tools used to assess body image to provide a context for the study findings to be presented. Subsequently, pertinent findings from these studies as they relate to body image and age; body image and treatment type; psychological and physical symptoms and body image; sexuality, intimacy, and body image; body image and the partnered relationship; and interventions and their impact on body image are also presented in the context of younger breast cancer survivors.
Characteristics of Included Studies
Study Design. A large portion of the articles included in this synthesis discussed cross-sectional studies, with few intervention studies assessing the impact of an intervention on body image outcomes. Of the 36 included articles, there were 24 cross-sectional investigations,2,7–9,19,26,29–46 5 were longitudinal studies,47–51 3 were qualitative explorations,52–54 2 were nonrandomized intervention studies,55,56 and 2 were randomized controlled trials57,58 (Table).
Participants. A total of 9343 breast cancer survivors participated across the studies included in this synthesis. Participants ranged in breast cancer diagnosis from stages 0 to III and from immediately posttreatment to as many as 5 years posttreatment. The majority of studies were conducted in the United States (n = 15)2,7,9,19,31,34,39,42,44,45,47,52,54,55,58 and Europe (n = 13),26,29,30,33,35,36,38,41,43,48,49,51,57 with the rest being conducted in Australia (n = 5),8,40,46,50,53 Iran (n = 2),32,37 and Korea (n = 1).56
Measurement Tools Used to Assess Body Image. There are a number of measurement tools that have been developed to assess body image, both generally and specifically when it comes to cancer survivors. There was a wide variation in assessment tools used to measure body image in these studies, which included a total of 13 different instruments (Table). Among the most common were the Body Image Scale (BIS) (Cronbach’s α = .93),4 which was utilized in 4 studies7,8,29,38; the European Organisation for Research and Treatment of Cancer Breast Cancer–Specific Quality-of-Life Module (EORTC-QLQ-BR23) (Cronbach’s α = .70–.91)59 used in 3 studies9,39,49; the EORTC Core Quality of Life Questionnaire (EORTC-QLQ-C30), comprised of multiple subscales, one of which assesses body image (Cronbach’s α = .52-.89),60 used in 1 study40; and the Cancer Rehabilitation Evaluation System (Cronbach’s α = .83),61 which was used in 4 studies.2,19,31,56 There were also 9 studies that utilized investigator-created or aggregated questionnaires specifically developed for their studies,33,37,41,42,50,57 3 of which were the qualitative studies included in the review.52–54
Body Image in Younger Breast Cancer Survivors
Body Image and Age. Cancer is generally viewed as a disease of aging, and the diagnosis of breast cancer can be devastating to a young woman.62 As a result, younger women are at particular risk for psychological symptoms during and after treatment, including body image issues. In this synthesis of the literature, 11 of the studies evaluated only younger women (Table),2,7,19,31,32,34,42,43,46,48,53 one of which compared younger women (aged ≤50 years) with control subjects, finding that there were significantly worse total body image scores among the younger breast cancer survivors (P < .01).32 Eight of the studies that compared younger women treated for breast cancer with older women treated for breast cancer found that the younger women in the study had worse body image compared with older women.8,9,30,38,40,49,51,53 Two studies comparing younger women treated for breast cancer with older women treated for breast cancer did not find a significant difference in body image by age,43,57 whereas 2 other studies found that younger women treated for breast cancer actually had a better body image perception than did older women treated for breast cancer.45,55
The remaining 13 studies did not report significant body image findings in younger women, but did report findings unique to younger women that could potentially be influenced by body image perceptions.26,29,33,35–37,39,41,47,52,54,56,57 One qualitative study identified a theme that women wanted age-specific concerns addressed.52 Other findings included younger women feeling less comfortable during intimacy,36,37 being more concerned about appearance,57 being more open to discussions of breast reconstruction,33,41 experiencing better outcomes related to body image with breast-conserving surgery,29,35,39,47 experiencing improved sexual satisfaction with an intervention for sexuality that also addressed body image,56 experiencing greater distress related to physical changes due to adjuvant treatment,54 and younger age being identified as a predictor of worse body image.26
Body Image and Treatment Type. It is understood that the various treatments for breast cancer that women may have to receive as part of their treatment can result in sudden and bothersome physical changes to the body. Many of the studies in this synthesis had findings related to the impact of treatment on body image, with a number of these findings being unique to younger women, including surgery type, chemotherapy, and radiation. Surgery type was found to have an impact on appearance satisfaction in 7 of the studies.7,29,31,39,43,47,51 Younger women were found to be more likely to opt for breast reconstruction36,41; women younger than 60 years who underwent reconstruction were found to have better body image than those younger than 60 years who did not undergo reconstruction (P = .0192), but this difference was no longer present in women older than 60 years,35 and younger age was found to be significantly associated with a desire for further plastic surgery to improve cosmetic results after breast-conserving surgery (P < .001).33 Adjuvant radiation was found to increase body image concerns54 and distress in younger women (P = .01),2 and chemotherapy treatment was also found to have a negative impact on body image among younger women (P < .05).7
Psychological and Physical Symptoms and Body Image in Younger Women. According to the American Cancer Society, most individuals will experience some level of anxiety, fear, and depression when cancer becomes a part of their lives, and people who experience physical symptoms associated with their cancer are more likely to experience emotional distress.63 In this synthesis, younger women were found to have higher levels of physical and psychological distress in 7 of the studies.2,19,34,40,44,49,58
Body image was found to be associated with both psychological and physical symptoms, including findings that body image concerns were significantly related to the psychological symptoms of anxiety, depression, fatigue, and fear of recurrence.2,40,44 In a study of women aged 25 to 50 years treated for breast cancer, poorer body image was significantly associated with emotional well-being (P < .01), breast cancer–specific concerns, (P < .0001), and health-related quality of life (P < .01).19 The study by Kenny et al40 had similar findings, in that younger women were found to have poorer emotional functioning (P = .0004), social functioning (P = .01), and global health status (P = .05). The 2010 longitudinal study by Hartl and colleagues49 also found that younger patients showed significantly greater impairment in both emotional and social functioning after surgical treatment (P = .00 for both) and that the impairment in emotional functioning was still present at 12 months after surgery (P = .036). Younger patients had higher scores for anxiety after primary surgical treatment (P = .016) than did older patients, and the younger patients’ scores maintained at the same level at the 1-year follow-up, whereas older women’s anxiety scores went down (P = .000).49
In terms of physical symptoms, Rosenberg et al2 found greater issues in younger women related to musculoskeletal pain (P < .0001) and the physical changes of weight gain (P = .01) and weight loss (P = .02). In addition, at baseline and 1 year, younger patients had more arm complaints (T1: P = .002 and T2: P = .038) and breast complaints (T1: P = .014 and T3: P = .001).2 Other studies reported that younger women had decreased physical strength (P < .001)34 and older women experienced greater improvement in strength and health (P = .03).58
Body Image and Sexuality. Sexuality, intimacy, and the partnered relationship are often associated with body image concerns in the breast cancer survivor. This was a particularly common finding in this synthesis, with 11 studies reporting these issues.7,30,32,34,36,37,40,43,52,56,57 Sexuality, intimacy, and body image concerns were found to be associated with younger age and treatment types received by younger women in this synthesis.
In terms of age, a number of studies identified greater issues related to sexuality and intimacy in younger women who participated. In the study conducted by Andrzejczak and colleagues,30 80% of women in the youngest group (34–49 years old) reported covering up their body for aesthetic reasons during intimate relations, whereas 73% in the middle-aged group (50–65 years old) and 58% in the oldest (>65 years old) reported the same behavior. Younger women were also found to place a greater importance on their breasts in sexuality and femininity (P = .009),40 and the study by Fobair and colleagues7 found that, in women 50 years or younger with breast cancer, sexual problems were associated with poorer body image (P < .05). In a qualitative exploration of African American women, the breast cancer survivors expressed needs for positive body image valuations as well as additional need for information about age-specific concerns related to body image and sexuality for younger women.52
Body Image and the Partnered Relationship. The diagnosis of breast cancer is devastating not only to the younger woman, but also to her partner and the intimate relationship.62 Five of the studies in this review also reported findings related to body image and the negative impact it may have on the partnered relationship for younger breast cancer survivors.7,26,34,50,53 Premenopausal women were found to have significant concerns related to changes in their relationships (P < .001),34 and women 50 years or younger experiencing greater body image concerns were associated with partner difficulty in understanding the feelings of the survivor (P < .05).7 King et al50 found that there was a negative impact of mastectomy on body image in married women, particularly younger married women (P = .0038). In a qualitative exploration of this topic among breast cancer survivors 50 years or younger, participants discussed their body image with respect to femininity and sexuality as a result of surgery, including 1 participant who expressed issues of body disfigurement because of breast surgery and another talking about her inability to feel desirable toward her husband as a result of breast surgery.53 Patients in a study that included breast cancer survivors up to age 50 years found that those who received a mastectomy have also been found to have a significantly greater concern about sexual role and performance when compared with those who received a lumpectomy (P < .01).43 In the study by Zimmerman and colleagues,26 age and male partner relationship satisfaction were found to predict women’s body image self-acceptance, whereas age, female relationship satisfaction, and common dyadic coping predicted perceived partner acceptance as an element of body image.
Intervention Research and Body Image After Breast Cancer. There were 4 studies in this review that used an intervention to address various aspects of recovery after breast cancer, including body image concerns.55–58 Two studies utilized an exercise intervention program55,58; another study used a sexual life reframing program intervention,56 and the final utilized a combination of a brief couples and sex therapy intervention.57
In the study published by Benton et al,55 participants were assigned to 1 of 2 parallel groups based on age (younger, aged 40–59 years or older; aged 60–80 years). Participants completed 8 resistance-training exercises 2 times per week for 8 weeks, and assessments were completed before and after intervention for both groups, with the investigator completing the intervention with participants on a one-on-one basis.55 In another study using an exercise intervention, women were randomly assigned to either a twice-weekly strength training intervention or a control group, with assessments taking place at baseline and again at a 12-month follow-up.58 These interventions were instructed by trained fitness professionals for the first 13 weeks, for approximately 90-minute sessions in groups of 2 to 6 survivors, and then unsupervised exercises continued for the remainder of the 12-month intervention period.58 Only 1 of the studies that used an exercise intervention reported a statistically significant improvement in body image for younger women compared with older women (P = .001),55 whereas the other exercise intervention study found that the intervention participants experienced greater improvement in body image at follow-up than did control subjects (P < .0001), with no effect found based on age of participants.58
In the study of couples after breast cancer, women who underwent a mastectomy and their partners were randomly assigned to either the Combined Brief Psychosexual Intervention group or control group with assessments taking place 2 days prior to the mastectomy and again 3 months after mastectomy.57 All interventions were delivered by the same therapist and consisted of 6 sessions, with the first taking place in the hospital after the mastectomy and subsequent sessions occurring biweekly with the couple and covering topics of communication training, sensate focus, and body imagery.56 In the study of a Sexual Life Reframing Program among Korean breast cancer survivors, participants were randomly assigned to the intervention or control groups and completed assessments at baseline and again postintervention.56 The intervention consisted of 6 weekly 2-hour small-group sessions focused on relaxation; problem perception; exposure; problem solving; acceptance, including body image; and reframing, including a reframing of thoughts and feelings about the self and body.56 In these remaining 2 studies, no statistically significant differences were found between the control and intervention groups over time for body image and also no statistically significant findings specific to age.56,57
Overall, the results of this synthesis found that age and treatment type had a significant impact on body image. In addition, poorer body image was found to have implications related to physical and psychological distress, sex and intimacy, the partnered relationship, and the potential for age to moderate body image in breast cancer survivors. Although there were intervention studies found that assessed the impact of an intervention on body image disturbance, only those that used an exercise component to the intervention found a statistically significant improvement in body image as a result of the intervention.
This review is the first to synthesize the published literature of body image in younger women after breast cancer treatment. The results of this systematic review demonstrate that body image disturbances are an important survivorship issue after breast cancer and that these issues are often associated with a variety of other distressing psychological, physical, and interpersonal concerns.
It is evident from this review that there is currently a large amount of cross-sectional data available that illustrate body image as a disturbing potential consequence of treatment for breast cancer. Cross-sectional data limit interpretation of the evidence, providing only a pinpoint view of this survivorship issue, and the few studies that performed longitudinal assessments found unresolved issues as long as 12 months after treatment.49 Whether due to younger age or the type of treatments received, there is evidence that body image disturbance is prevalent and often associated with other issues such as sexual functioning in the breast cancer survivor population and that it is particularly distressing to the younger survivor population.
In order to determine the relationship between treatment regimens and body image and to compare perceptions of body image prior to and after treatment, further research using prospective study designs is recommended. In addition, interventions to assist with the improvement of these symptoms after treatment would be the next logical step in the progression of research in this area. However, this synthesis showed that the evidence related to interventions for body image in younger breast cancer survivors is limited, as only 4 studies tested an intervention in the literature review55–58 and of these, only the 2 that used an exercise component to the intervention showed any statistically significant differences related to body image.55,58 As a result, it would be pertinent to pursue further empirical investigations of interventions that use an exercise component and to assess the ability of these interventions to improve body image, particularly among younger women after breast cancer treatment. A recent meta-analysis to determine the effects of exercise interventions after treatment for breast cancer also supports this recommendation, finding that exercise interventions significantly improved body image among breast cancer patients, calling for further research into the effect of exercise on stress and the combined effect of behavioral and physical exercise interventions in breast cancer survivors.64
Another issue related to the literature review is the wide variation in multiple aspects of the studies included. There was an extensive array of assessment tools used to assess body image, including a number of articles that used questions or assessments developed for that particular study that had not been tested for their validity or reliability. The use of validated and reliable instruments to empirically measure body image is imperative if progress is to be made in developing a more cohesive understanding of the elements that contribute to this complex survivorship issue. Of the various assessment tools used to assess body image that were identified through this synthesis, the psychometric properties of the BIS and EORTC-QLQ-BR23, provide support for their consistent use in assessing body image in breast cancer patients. The BIS has a Cronbach’s α of .93 and is a short, 10-item scale developed for use with cancer patients.4 The EORTC-QLQ-BR23 is a 23-item scale specific to breast cancer patients that assesses symptoms and adverse effects related to different treatment modalities, body image, sexuality, and future perspective and the Cronbach’s α ranges from .70 to .91.59 It is imperative that valid, reliable measurement tools such as these be used In order to develop a strong body of evidence related to the impact of body image concerns in breast cancer patients and survivors.
Furthermore, there was a large variation in the time since treatment among these studies, with some assessing women immediately following their treatment, within weeks after, and others assessing women as many as 5 years since treatment. Across these studies, it was found that younger women were still experiencing body image disturbance as well as other distressing symptoms. Finally, generally small sample sizes and limited diversity of the participants in the studies included in this synthesis place further restrictions on the confidence one can have generalizing the results to breast cancer survivors as a whole.
This review of literature has some potential limitations. First, the span of publications was limited to the years 2000 to 2014 to target the impact of current treatments related to body image and younger breast cancer survivors in the published literature. There is a chance of “file-drawer” bias, as only published articles were included in the review. In addition, limiting the results to those that included age-related outcomes focused on younger women may potentially bias the results and limit the understanding of the implications of other factors in older women with breast cancer. However, the scope of this review was to identify those age-related outcomes that are unique to or more severe in the younger breast cancer survivor.
Implications for Nursing Research
As discussed, body image is a concept that is part of the overall sexual health, and this is considered one of the aspects of health for any individual.21 Through this synthesis, body image concerns have been found to be associated with other physical and psychological symptoms as well as impacting the partnered relationship and sexuality of survivors.
The need for future research is great in this particular area. The smaller sample sizes and wide variation in measurement tools used to assess body image in many of the studies discussed in this synthesis further limit the understanding of body image disturbance across all breast cancer survivors. The design of research that is necessary for the future lies with rigorously implemented prospective studies and randomized clinical trials. It is important that these trials implement consistent assessment methods targeted at assessing and decreasing the body image disturbance experienced by breast cancer survivors and improving their quality of life and ameliorate these symptoms. In addition, there is a great need for further evaluation of the younger population as a particularly high-risk group of breast cancer survivors who are more likely to manifest body image disturbance issues after treatment.
Although further empirical research is needed in this area, the nurse caring for an individual as they navigate the cancer diagnosis and treatment process is in an ideal situation to conduct an assessment of body image and sexuality concerns and to start an open dialogue regarding these topics. This rapport can make it easier for patients to feel comfortable discussing their concerns related to these sensitive topic areas with the nurse, and in turn, the nurse will be able to provide the patient with resources to help patients better understand and address these concerns after cancer treatment. While the National Cancer Institute acknowledges that further research related to interventions for sexuality and body image is necessary, they have resources available to the nurse that can be used to address and discuss these concerns with breast cancer patients.65 This is an important issue in treatment and survivorship care and one that needs to be addressed with patients on a regular basis throughout the cancer continuum.
Results of this review showed that body image concerns are prevalent among younger women, with treatment type, including greater concerns among survivors related to both surgery types (lumpectomy vs mastectomy) and adjuvant treatment. Younger women also experienced increased levels of physical and psychological symptoms, often unresolved in follow-up treatment. Particularly, issues related to sexuality and intimacy were of great concern to the breast cancer survivor, and evidence that the partnered relationship suffers as a result of body image concerns after breast cancer treatment was also found through this synthesis. Body image disturbance clearly has the potential to cause difficulties in recovery from breast cancer. Younger women are at particularly high risk for this negative adverse effect after treatment, both because of their life stage and because of the more aggressive treatments that are often associated with the more aggressive cancers that present in younger women. It is imperative that further research be conducted in this area to improve these symptoms, particularly in the high-risk younger breast cancer survivor population. The review of the literature identified body image disturbance as a significant issue for breast cancer survivors, but further research and well-designed randomized design trials using validated and reliable measures of body image are necessary to determine which interventions would be most effective in reducing body image disturbance and improving the quality of life of these women as they transition into survivorship.
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