Keywords
breast cancer - body image - self-esteem
Palavras-chave
câncer de mama - imagem corporal - autoestima
Introduction
Cancer is a group of diseases that have cluttered cell growth, with property of invasion
of other organs and tissues, featuring the metastasis.[1]
Among all cancers, breast cancer is the one with the highest rate of cancer death
worldwide, and is increasing in developing countries, where most cases are diagnosed
in advanced stages.[2]
Currently, breast cancer is considered a public health issue in many countries.[3] Its incidence increased by more than 20% between 2008 and 2012, while mortality
from breast cancer increased by 14% in 140 countries.[4] In Brazil, the prevalence of breast cancer also increased, reflecting the increase
in the number of survivors of this disease.[5] Nevertheless, the same treatment that offers better cure rates may often result
in serious emotional harm, diminishing the women's quality of life and provoking changes
in their bodies.[6]
The breast is the epitome of femininity, and anything that affects it leads women
to question their roles as attractive, feminine individuals and breastfeeding mothers.
Body image affects self-esteem and sexuality; therefore, understanding these issues
is a way of understanding the female universe.[7]
Body image encompasses self-perception and attitudes related to the body that involve
thoughts, beliefs, feelings and behaviors.[8]
With respect to the physical changes that may occur, body image has been studied in
many different ways. Some authors have reported that body image is related to self-image
and self-esteem. In this respect, women understand the female body as a vehicle for
communicating their femaleness to the world.[9]
Self-esteem is defined as a set of impressions that the individual has of him or herself
that involve self-assessment, lifestyle and ideas about oneself that can be positive
or negative.[10] Thus, individuals with low self-esteem have difficulties employing suitable social
strategies; they continually face the conflict to take the challenge to succeed and,
therefore, earn the approval of others and of themselves. At the same time, they run
the risk of failing and earning the disapproval of others and of themselves.[11]
Evaluating the effect of the type of breast cancer treatment on body image and on
self-esteem is extremely relevant, since women with breast cancer participate in the
decision-making process regarding their treatment.[12] Self-esteem has been found to be higher in mastectomized women who were submitted
to breast reconstruction compared with those who were not.[13] Hence, the loss of an eroticized organ that is capable of provoking desire in others
may damage a woman's physical structure, leading her to feel that she has lost her
physical attractiveness, her femininity, possibly leading to diminished self-esteem.[14]
Surgical treatment for breast cancer can be subdivided into breast-conserving therapy
(quadrantectomy) or mutilating surgery (mastectomy). The defect resulting from the
surgery can be repaired during the same surgical procedure (immediate reconstruction)
or afterwards (late reconstruction).[15]
Following the surgical treatment, women submitted to mastectomy who do not undergo
breast reconstruction experience a feeling of inferiority, since the breast is an
organ that is replete in symbolism and indeed symbolizes the concept the woman has
of herself. Mastectomy involves the loss of the former figure and harms the image
the women make of their bodies; it is considered an attack on body image, which makes
patients feel they are not beautiful.[16]
Therefore, understanding that women undergoing breast cancer treatment have poor self-esteem
and altered body image, the objective of the present study was to investigate the
self-esteem related to body image in women with and without breast cancer, and to
seek correlations between body image and the self-esteem of these patients.
Methods
This case-control study involved women with and without breast cancer.
Participants
The participants were invited to take part in the study between March 2011 and February
2013 at the Mastology Program of a teaching hospital in the city of Goiânia, in the
Brazilian Midwest region.
Total 257 women diagnosed with breast cancer were treated at the Mastology Program
between 2011 and 2013. In 2011, 58 patients were treated; in 2012, 59 patients; and,
in 2013, 140 patients were treated.
The possible participants were approached during the medical consultation, and those
who accepted to participate were forwarded to the Psychology Room, a space created
by the Mastology Program. The participants were then divided into two groups: the
case group consisted of patients with breast cancer, and the control group was composed
by the patients' companions. It is important to remember that the participants from
both groups shared the same sociodemographic data: age, marital status, level of schooling,
income and origin.
Inclusion and Exclusion Criteria
Inclusion Criteria for the Cancer Group
-
Patients older than eighteen years.
-
Patients who underwent conservative surgery or mastectomy with or without immediately
breast reconstruction, performed between one month to five years.
-
Patient receiving neoadjuvant chemotherapy (which have not undergone the surgery).
Inclusion Criteria for the no Cancer Group
Women over 18 who were in the waiting room of Mastology HC Program / (companions of
patients awaiting medical consultation).
Exclusion Criteria for the Cancer Group
-
Patients with metastatic disease without curative intention of cancer treatment.
-
Patients with neuropsychiatric disorders.
-
Patients who had cognitive impairment.
-
Patient receiving adjuvant chemotherapy (which were submitted to surgery).
Exclusion Criteria for the no Cancer Group
-
Women who have had their breasts plastic surgically, resulting in asymmetric breasts.
-
Women with neuropsychiatric disorders.
-
Women who had cognitive impairment.
Sample
There original sample comprised 92 women with breast cancer. However, two failed to
answer all the questions of the instrument applied, resulting in a final sample of
90 women who fulfilled all of the selection criteria. The control group consisted
of 77 women recruited among the relatives/friends who were accompanying the patients
registered at the Mastology Program of the teaching hospital. Therefore, the final
sample included 167 participants who were chosen randomly. The study had a significance
level of 5% and 80% test power, with a margin of error of 2.63. The sample size was
set at 90 subjects in total, and in order to make the necessary calculations for the
study, we used as reference the article written by Manos et al.[17]
Ethical Aspects
This study also aimed to show respect for the patients and the institution in which
it took place. To that end, we followed Resolution no. 466/12 of the Brazilian National
Health Council, which regulates research involving human beings in the country. Before
any procedure, the participants were informed about the study's goals and purpose.
The study considered refusal as a possibility, and that did not imply any damage to
the volunteers. It was approved by the Ethics Research Committee (CEP) of the institution
under protocol number 195/2010.
Instruments
The participants were interviewed for the purpose of obtaining their sociodemographic
data. In addition, the following two instruments were applied:
-
Body Satisfaction Scale (BSS)
In order to evaluate satisfaction with body image, a scale adapted and validated in
Brazil by Ferreira and Leite[18] was used. The questionnaire contains 25 questions with responses given on a Likert-like
scale ranging from 1 (totally disagree) to 5 (fully agree). This instrument was based
on two questionnaires: The Body-Esteem Scale (BES) developed by Mendelson et al in
1997, and The Multidimensional Body-Self Relations Questionnaire (MBSRQ) developed
by Cash in 1994. The BSS[18] evaluates two factors or subscales: the degree of satisfaction with one's own appearance;
and the concern regarding one's weight. The value of Cronbach's α measured for these
factors was 0.90 and 0.79 respectively. In this scale, the items that refer to appearance
are items 1, 2, 6, 7, 8, 11, 12, 14, 15, 17, 20, 22, 23, 26, 27, 30, 31 and 32. The
items related to weight are items 4, 8, 16, 18, 24, 28 and 29. The two subscales are
corrected to obtain the individual satisfaction level. The higher the score, the less
concern the individual has with respect to weight, and the greater the satisfaction
with his/her own body image. In other words, the higher the score awarded for each
factor in the scale, the higher the level of satisfaction with the body image. Correction
is performed by adding factors to the mean score. In the case of the negative items
(items 4, 7, 9, 11, 17, 18, 24, 27, 28 and 29), the score is inverted.
-
Rosenberg Self-Esteem Scale (RSES)
The Rosenberg Self-Esteem Scale, developed by Morris Rosenberg in 1956 and revised
by the same author in 1989, and translated and adapted for use in Portuguese by Avanci
et al[19], was used. The scale evaluates an individual's attitude and positive and negative
feelings about him/herself, and encompasses questions on personal satisfaction, self-deprecation,
and perception of qualities, competence, self-pride, self-worth, respect and feelings
of failure. Self-esteem is then classified based on a final score of 10–40 points.
A score of 26–40 points is classified as high self-esteem, while a score of 10–25
points is indicative of low self-esteem. Thus, the self-esteem questionnaire bears
a two-dimensional structure (positive or negative). The overall self-esteem contributes
substantially to the description of the latent construct. Global self-esteem is calculated
by subtracting the high self-esteem score from the low self-esteem score. The questionnaire
consists of 10 closed questions that are evaluated on a Likert-type scale in which
1 represents full agreement, and 4, complete disagreement. The value of Cronbach's
α measured was 0.68.
Statistical Analysis
Data were inserted into a Microsoft Excel (Microsoft, Redmond, WA, US) spreadsheet,
and the statistical analysis was performed using the Statistical Package for the Social
Sciences (IBM-SPSS, Chicago, Il, US) software, version 16.0. A univariate analysis
was used to compare the groups with respect to their sociodemographic profiles. Student's
t-test was used to evaluate the results of body image and self-esteem as a function
of the therapeutic procedures to which the women in the case group were submitted.
Pearson's correlation coefficient was used to verify correlations between the domains
of body image and self-esteem in the case group. The significance level was established
at 5% (p < 0.05).
Results
The case group consisted of 90 women with breast cancer. The age of these women ranged
from 31 to 88 years (mean 50 years; standard deviation [SD] 10.3 years). The control
group consisted of 77 women without breast cancer. The age of these women ranged from
31 to 77 years, with a mean of 48 years (SD: 11.1 years).
The results of the comparison between the groups were adjusted by the following variables:
age group, marital status, level of education, religion, job, income and origin. They
are described in [Table 1]. The comparison showed that the groups were similar, except when it came to religion
(p = 0.042), in which there were more Evangelicals in the cancer group, and profession,
especially, in the case of the Seamstress (p = 0.02).
Table 1
Comparison of the sociodemographic characteristics of the case and control groups
|
Group
|
Case
|
Control
|
p
|
OR
|
95%CI
|
|
n
|
%
|
n
|
%
|
Lower
|
Upper
|
|
Age Group
|
|
31–40 years
|
12
|
13.3
|
19
|
24.7
|
0.07
|
0.38
|
0.14
|
1.05
|
|
41–50 years
|
34
|
37.8
|
23
|
29.9
|
0.80
|
0.89
|
0.36
|
2.17
|
|
51–59 years
|
24
|
26.7
|
23
|
29.9
|
0.33
|
0.63
|
0.25
|
1.58
|
|
≥ 60 years
|
20
|
22.2
|
12
|
15.6
|
0.170
|
0.81
|
0.59
|
1.10
|
|
90
|
100.0
|
77
|
100.0
|
|
|
|
|
|
Marital status
|
|
Single
|
41
|
45.6
|
27
|
35.1
|
|
|
|
|
|
Married
|
49
|
54.4
|
50
|
64.9
|
0.170
|
1.55
|
0.83
|
2.90
|
|
Total
|
90
|
100.0
|
77
|
100.0
|
|
|
|
|
|
Level of schooling
|
|
Illiterate
|
7
|
7.8
|
3
|
3.9
|
0.22
|
3.27
|
0.51
|
24.84
|
|
Lower than high school
|
47
|
52.2
|
48
|
62.3
|
0.38
|
1.84
|
0.47
|
7.89
|
|
High school
|
32
|
35.6
|
20
|
26.0
|
0.23
|
2.37
|
0.58
|
10.58
|
|
Higher education
|
4
|
4.4
|
6
|
7.8
|
0.926
|
1.02
|
0.66
|
1.59
|
|
Total
|
90
|
100.0
|
77
|
100.0
|
|
|
|
|
|
Religion
|
|
Catholic
|
34
|
38.2
|
40
|
51.9
|
0.042
|
0.61
|
0.37
|
0.98
|
|
Evangelical
|
49
|
55.1
|
35
|
45.5
|
0.12
|
1.64
|
0.87
|
3.11
|
|
Spiritist
|
1
|
1.1
|
1
|
1.3
|
0.92
|
1.17
|
0.03
|
47.0
|
|
Others
|
5
|
5.6
|
1
|
1.3
|
0.10
|
5.77
|
0.75
|
143.2
|
|
Total
|
89
|
100.0
|
77
|
100.0
|
|
|
|
|
|
Occupation
|
|
Housewife
|
50
|
55.6
|
30
|
39.0
|
0.97
|
0.97
|
0.33
|
2.75
|
|
Nursing technician
|
3
|
3.3
|
2
|
2.6
|
0.90
|
0.88
|
0.11
|
9.00
|
|
Salesperson
|
6
|
6.7
|
3
|
3.9
|
0.88
|
1.16
|
0.21
|
7.29
|
|
Housemaid
|
5
|
5.6
|
11
|
14.3
|
0.07
|
0.28
|
0.06
|
1.12
|
|
Dressmaker
|
3
|
3.3
|
11
|
14.3
|
0.02
|
0.17
|
0.03
|
0.79
|
|
Receptionist
|
2
|
2.2
|
2
|
2.6
|
0.66
|
0.60
|
0.05
|
6.83
|
|
Retired
|
8
|
8.9
|
6
|
7.8
|
0.74
|
0.78
|
0.18
|
3.37
|
|
Teacher
|
1
|
1.1
|
5
|
6.5
|
0.07
|
0.13
|
0.00
|
1.14
|
|
Others
|
12
|
13.3
|
7
|
9.1
|
0.170
|
1.08
|
0.97
|
1.19
|
|
Total
|
90
|
100.0
|
77
|
100.0
|
|
|
|
|
|
Income
|
|
≤ 1 MW
|
39
|
45.9
|
25
|
33.3
|
0.195
|
1.74
|
0.75
|
4.01
|
|
1–2 MW
|
29
|
34.1
|
31
|
41.3
|
0.920
|
1.05
|
0.46
|
2.39
|
|
≥ 3 MW
|
17
|
20.0
|
19
|
25.3
|
0.145
|
1.35
|
0.90
|
2.03
|
|
Total
|
85
|
100.0
|
75
|
100.0
|
|
|
|
|
|
Origin
|
|
Capital city (Goiânia)
|
55
|
61.1
|
42
|
54.5
|
0.590
|
1.17
|
0.65
|
2.11
|
|
Cities in the interior of the state
|
33
|
36.7
|
35
|
45.5
|
|
|
|
|
|
Others States
|
2
|
2.2
|
0
|
0.0
|
|
|
|
|
|
Total
|
90
|
100.0
|
77
|
100.0
|
|
|
|
|
Abbreviations: 95% CI, 95% confidence interval; MW, minimum wage; OR, odds ratio.
Note: Univariate analysis test; values of p ≤ 0.05 were considered statistically significant.
The results for body image related to weight, body image related to appearance, and
self-esteem in both groups are described in [Table 2]. A significant difference was found between the groups with respect to appearance
(with scores of 56.71 for the case group and 66.75 for the control) (p = 0.001), that is, the women with breast cancer felt their appearances were compromised.
Table 2
Comparison between both groups in relation to the domains of body image and self-esteem
|
Group
|
Case (n = 90)
|
|
Control (n = 77)
|
|
p
|
Student's t-test
|
|
Mean
|
Median
|
SD
|
Mean
|
Median
|
SD
|
|
Body image – weight
|
23.98
|
23.50
|
6.84
|
23.10
|
23.00
|
7.57
|
0.435
|
0.783
|
|
Body image – appearance
|
56.71
|
56.00
|
17.58
|
66.75
|
71.00
|
19.02
|
0.001
|
−3.522
|
|
High self-esteem
|
12.24
|
13.00
|
2.21
|
12.73
|
14.00
|
2.73
|
0.209
|
−1.262
|
|
Low self-esteem
|
4.36
|
4.00
|
3.24
|
3.51
|
3.00
|
2.82
|
0.075
|
1. 789
|
|
Overall self-esteem
|
7.89
|
8.50
|
4.55
|
9.22
|
10.00
|
4.98
|
0.073
|
−1.805
|
Abbreviation: SD, standard deviation of the mean.
Note: Values of p ≤ 0.05 were considered statistically significant.
[Table 3] describes the results of the body image and self-esteem domains for the case group
as a function of whether or not they had been submitted to neoadjuvant chemotherapy.
Statistically significant differences were found only for body image related to appearance
(p = 0.019) and high self-esteem (p = 0.031).
Table 3
Comparison of the variable chemotherapy in relation to the domains of body image and
self-esteem in the case group
|
Chemotherapy
|
Yes (n = 22)
|
No (n = 68)
(Patients who underwent surgery)
|
p
|
Student's t-test
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Body image – weight
|
24.23
|
6.27
|
23.90
|
7.06
|
0.845
|
0.196
|
|
Body image – appearance
|
49.14
|
18.45
|
59.19
|
16.68
|
0.019
|
−2.390
|
|
High self-esteem
|
11.36
|
2.46
|
12.53
|
2.06
|
0.031
|
−2.197
|
|
Low self-esteem
|
4.55
|
3.61
|
4.29
|
3.14
|
0.754
|
0.314
|
|
Overall self-esteem
|
6.82
|
5.37
|
8.24
|
4.24
|
0.206
|
−1.275
|
Abbreviation: SD, standard deviation of the mean.
Note: Values of p ≤ 0.05 were considered statistically significant.
The results of the comparative analysis of the body image and self-esteem domains
of the case group as a function of whether or not they had been submitted to mastectomy
are described in [Table 4]. A statistically significant difference was found only for appearance (p = 0.001). [Table 4] also shows the results of the comparative analysis of the body image and self-esteem
domains for the women in the case group as a function of whether or not they had been
submitted to breast conserving therapy. A statistically significant difference was
found only for the appearance domain (p < 0.001), with the women who had undergone breast conserving therapy reporting being
more satisfied with their physical appearance.
Table 4
Comparison of the variables mastectomy and breast-conserving therapy in relation to
the domains of body image and self-esteem in the case group
|
Mastectomy
|
Yes (n = 23)
|
No (n = 67)
|
p
|
Student's t-test
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Body image – weight
|
23.35
|
5.74
|
24.19
|
7.21
|
0.612
|
−0.509
|
|
Body image – appearance
|
46.00
|
14.02
|
60.22
|
17.28
|
0.001
|
−3.497
|
|
High self-esteem
|
12.17
|
2.15
|
12.27
|
2.25
|
0.860
|
−0.176
|
|
Low self-esteem
|
4.52
|
2.74
|
4.30
|
3.42
|
0.778
|
0.283
|
|
Overall self-esteem
|
7.65
|
3.54
|
7.97
|
4.87
|
0.774
|
−0.288
|
|
Breast conserving therapy
|
Yes (n = 21)
|
No (n = 69)
|
p
|
Student's t-test
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Body image - weight
|
22.71
|
7.87
|
24.36
|
6.52
|
0.337
|
−0.960
|
|
Body image - appearance
|
69.48
|
10.94
|
52.76
|
17.41
|
< 0.001
|
4.144
|
|
High self-esteem
|
12.86
|
2.33
|
12.06
|
2.15
|
0.148
|
1. 460
|
|
Low self-esteem
|
4.52
|
3.66
|
4.30
|
3.14
|
0.788
|
0.270
|
|
Overall self-esteem
|
8.33
|
5.32
|
7.75
|
4.32
|
0.612
|
0.509
|
Abbreviation: SD, standard deviation of the mean.
Note: Values of p ≤ 0.05 were considered statistically significant.
A comparative analysis of the domains of body image and self-esteem of the case group
in relation to whether or not they had undergone breast reconstruction showed no statistically
significant differences.
The results of the correlation analysis between the domains of body image and self-esteem
of the case group are described in [Table 5]. A statistically significant negative correlation was found between body image related
to weight and low self-esteem (p = 0.039) and overall self-esteem (p = 0.034). A statistically significant negative correlation was found between body
image related to appearance and high self-esteem (p < 0.001), and low self-esteem (p < 0.001) and overall self-esteem (p < 0.001). A statistically significant negative correlation was found between high
self-esteem and low self-esteem (p < 0.001) and overall self-esteem (p < 0.001). Finally, a statistically significant negative correlation was found between
low self-esteem and overall self-esteem (p < 0.001).
Table 5
Correlation between the domains of body image and self-esteem in the case group
|
Domains
(n = 90)
|
Body image
|
High self-esteem
|
Low self-esteem
|
Overall self-esteem
|
|
Body image – weight
|
|
r
|
0.130
|
0.140
|
−0.218
|
0.223
|
|
p
|
0.223
|
0.188
|
0.039
|
0.034
|
|
Body image – appearance
|
|
r
|
|
0.367
|
−0.389
|
0.456
|
|
p
|
|
< 0.001
|
< 0.001
|
< 0.001
|
|
High self-esteem
|
|
r
|
|
|
−0.368
|
0.748
|
|
p
|
|
|
< 0.001
|
< 0.001
|
|
Low self-esteem
|
|
r
|
|
|
|
−0.892
|
|
p
|
|
|
|
< 0.001
|
Abbreviations: r, Pearson's correlation coefficient; SD, standard deviation of the
mean.
Note: Values of p ≤ 0.05 were considered statistically significant.
Discussion
The results of the present study show differences between the case and control groups
with respect to body image and self-esteem. There was a significantly higher mean
score for body image related to appearance in the control group compared with the
case group. This finding shows that the surgical intervention negatively affected
the perception of the women in the study group regarding their body image related
to appearance. These results confirm that Brazilian women are usually anxious about
their appearance prior to undergoing mastectomy.[20] Other studies have reported that women who were submitted to breast conserving therapy
and those submitted to mastectomy with breast reconstruction value their appearance.[21]
We also found that having to undergo chemotherapy resulted in a significant reduction
in the scores achieved for body image related to appearance and high self-esteem.
Nevertheless, this treatment did not affect body image in relation to weight, low
self-esteem or overall self-esteem in the case group. Patients undergoing chemotherapy
report great concern regarding hair loss, resulting in anxiety, distress and dismay.[22] This may be one of the reasons behind the results found in this study regarding
appearance in patients undergoing chemotherapy. Other authors found that chemotherapy,
apart from modifying body image, also changes the self-esteem of women, compromising
their social relations.[23] A study conducted in Korea showed a moderate correlation between distress related
to hair loss and body image, but not with self-esteem.[24] Indeed, patients undergoing chemotherapy and those submitted to breast-conserving
therapy do not appear to have problems seeing themselves naked.[25]
Of the body image domains evaluated in the present study, having been submitted to
mastectomy resulted in a negative effect only on body image related to appearance.
This type of treatment is understood to represent a major challenge for women, exerting
a negative effect on emotional and social aspects. The data presented are in agreement
with the findings of another study that showed that patients submitted to mastectomy
are very concerned with their body image.[26] According to a study conducted in northern Taiwan, concern regarding body image
increased significantly in 41.5% of young patients with breast cancer.[27] With respect to the cosmetic aspects of mastectomy, patients have described it as
a “terrible mutilation” that is emotionally devastating and leads them to avoid social
interactions and physical intimacy.[28]
[29] Another study showed that 67% of mastectomized patients felt inadequate in regard
to their femininity, and found it difficult to accept their new body.[30] A comparative study between mastectomy and breast-conserving therapy showed that
38% of the patients submitted to mastectomy declared that they were dissatisfied with
their body image, while patients who had been submitted to breast-conserving therapy
did not report dissatisfaction with their body.[31]
Patients submitted to breast-conserving therapy were found to be more satisfied with
their appearance, with higher levels of satisfaction with their body image compared
with those submitted to mastectomy with breast reconstruction. These findings are
in agreement with those reported in a study conducted in Germany, in which a sample
of 112 patients was evaluated, with results showing that the women submitted to breast-conserving
therapy had a better image of their body compared with those submitted to mastectomy
and reconstruction.[32] Another study, conducted in Greece, also showed satisfaction with body image following
breast-conserving therapy.[33] A study conducted in the United States found that body image remained unaffected
in 57.6% of patients submitted to breast-conserving therapy, while 6.1% declared that
their perception of body image was poorer, and 36% stated that it was better. The
patients who were dissatisfied with the results of the surgery were more likely to
evaluate their physical image negatively compared with patients who were satisfied.[34]
No statistically significant differences were found in the appearance domains or self-esteem
of the case group when women who had undergone breast reconstruction were compared
with those who had not, that is, having undergone breast reconstruction made no difference
to the body image or self-esteem domains in these women. Therefore, patients undergoing
this type of treatment have neither a negative perception of their body nor poor self-esteem.
A study conducted in Spain reported conflicting results, with patients submitted to
breast reconstruction reporting greater satisfaction with their body image and higher
self-esteem.[13] In the United States, a study published in 2013 found that 63.9% of women had positive
expectations regarding their body image following surgery for breast reconstruction.[35] It has also been reported that women submitted to breast reconstruction report greater
satisfaction with their abdominal region, whereas women submitted to breast-conserving
therapy are more satisfied with the appearance of their breasts.[36]
As a possible limitation of this study, it is important to mention that the differences
found in the treatment variables in the case group may reflect the different religious
beliefs of the women; however, the variable religion was not a control factor in the
selection of this sample.
Another limitation of this study refers to the questionnaires, as there was a large
number of women who refused to participate. Therefore, the time of data collection
for the group of women without breast cancer was also a limitation of the study, because
it was not possible to apply 90 questionnaires to women without breast cancer.
Conclusion
The results of this study show that self-esteem is negatively affected in patients
who are dissatisfied with their body image. In conclusion, the study found women with
breast cancer to be more dissatisfied with their body image related appearance compared
with women without breast cancer, particularly after mastectomy or during chemotherapy.
There was also a weak correlation between the body image and self-esteem domains,
showing the influence of the former over the latter
