Abstract
Background
Breast cancer surgery can substantially affect body image and self-esteem, particularly after mastectomy. Although breast reconstruction may be associated with more favourable psychosocial outcomes, the body-image dimensions underlying differences in self-esteem remain incompletely understood. This study examined cross-sectional associations among surgical status, body image, and self-esteem in women with breast cancer.
Methods
A multicentre cross-sectional study included 450 women: mastectomy with reconstruction (n = 150), mastectomy without reconstruction (n = 150), and a non-mastectomy comparison group (n = 150), comprising women without documented mastectomy at assessment. Self-esteem and body-image dimensions were assessed using validated questionnaires. Group differences were analysed using adjusted analysis of covariance, hierarchical regression, exploratory cross-sectional indirect-effect analysis with 5,000 bootstrap resamples, and multivariable logistic regression.
Results
Self-esteem and body-image scores differed significantly across groups after adjustment for sociodemographic and clinical characteristics (all p < 0.001). Women who underwent mastectomy without reconstruction reported the lowest self-esteem (26.7 ± 5.8), followed by women with reconstruction (32.9 ± 5.1), whereas the non-mastectomy comparison group reported the highest scores (37.4 ± 4.2). Appearance evaluation (β = 0.46) and fear of negative appearance evaluation (β = −0.34) were the strongest correlates of self-esteem (both p < 0.001). The final model explained 60% of the variance (adjusted R2 = 0.58). Body-image domains statistically accounted for approximately 89% of the cross-sectional association between surgical status and self-esteem. Recurrence history independently predicted low self-esteem (adjusted OR = 2.18, 95% CI: 1.29–3.68).
Conclusions
Body-image domains were strongly associated with self-esteem and statistically accounted for a substantial proportion of the cross-sectional association between surgical status and self-esteem. Women with reconstruction reported higher self-esteem than those without reconstruction, although scores remained lower than the non-mastectomy comparison group. Body-image assessment and psychosocial support may be valuable components of survivorship care; however, prospective studies are needed to evaluate targeted interventions.
Introduction
Breast cancer remains one of the most commonly diagnosed malignancies among women worldwide and represents a major survivorship concern because its impact extends beyond survival to long-term psychological and social well-being (Bray et al., 2024; Sung et al., 2021). Advances in screening, surgery, systemic therapy, radiotherapy, and supportive care have increased attention to patient-reported outcomes, including body image, self-esteem, emotional adjustment, sexual confidence, and quality of life (Fallbjörk et al., 2013; Paterson et al., 2016).
Mastectomy remains an important surgical option for selected women with breast cancer. Removal of breast tissue may nevertheless affect psychological adjustment because the breast may be closely connected with femininity, sexuality, attractiveness, motherhood, and personal identity (Helms et al., 2008). Surgical scarring, asymmetry, altered sensation, and concerns about how the body is perceived by oneself and others may contribute to body-image distress, reduced confidence, intimacy concerns, and lower self-esteem (Helms et al., 2008; Ljungman et al., 2018; Paterson et al., 2016). Body image is multidimensional and includes evaluative, emotional, cognitive, behavioural, and social components, whereas self-esteem reflects a broader evaluation of personal worth and self-acceptance (Rosenberg, 1965; Tylka & Wood-Barcalow, 2015).
Breast reconstruction is offered to restore breast contour and may be associated with improved breast-related satisfaction and quality of life (Miseré et al., 2021; Zehra et al., 2020). However, psychological findings remain mixed, and some women report persistent dissatisfaction or appearance-related distress after reconstruction (Teo et al., 2018; Weingarden et al., 2022). Variation across studies may reflect differences in reconstruction type and timing, postoperative complications, time since surgery, patient selection, baseline expectations, and the extent to which surgical outcomes meet those expectations. Reconstruction should therefore not be assumed to produce uniform psychological outcomes.
Psychological adjustment after breast cancer surgery is also shaped by clinical, socioeconomic, interpersonal, and cultural conditions. In Iraq and other Middle Eastern settings, expectations related to femininity, marriage, modesty, family roles, and appearance may influence how treatment-related bodily changes are interpreted. Yet evidence from these populations remains limited, and international findings may not fully capture the healthcare access, reconstructive options, and social context experienced by Iraqi women.
A multidimensional approach may help explain why women with similar surgical experiences report different levels of self-esteem. Appearance evaluation captures satisfaction with and perceived attractiveness of the body; appearance orientation reflects the attention and behavioural investment directed toward appearance; and fear of negative appearance evaluation captures concern about being judged unfavourably by others. These domains represent complementary cognitive-affective, behavioural, and social-evaluative processes that may accompany the association between surgical experience and global self-worth (Teo et al., 2018; Tylka & Wood-Barcalow, 2015; Weingarden et al., 2022).
Clarifying which appearance-related processes are most closely associated with self-esteem has potential clinical value. It may help clinicians move beyond surgery-based assumptions, identify women who could benefit from focused assessment or psychosocial referral, and support realistic expectation-setting before and after reconstruction. This information may be particularly useful for culturally responsive survivorship care in settings where access to reconstruction and social expectations differ from those represented in much of the international literature.
The present study addressed two related gaps by comparing three clinical groups within one Iraqi sample and by examining several body-image dimensions within the same analytical framework. The groups comprised women who underwent mastectomy with reconstruction, women who underwent mastectomy without reconstruction, and a non-mastectomy comparison group. In this manuscript, the latter term refers to women who had not undergone mastectomy by the assessment date; detailed local-treatment pathways, including whether breast-conserving surgery had been completed, were not consistently recorded and were therefore not used to define the group. The study compared self-esteem and body-image outcomes across groups, examined their adjusted associations, and explored whether body-image domains statistically accounted for part of the cross-sectional association between surgical status and self-esteem.
Methods
Study design and reporting framework
This multicentre cross-sectional analytical study was conducted among women diagnosed with breast cancer in Iraq between December 2025 and April 2026. Group allocation was observational and was based on surgical history documented through medical-record review and participant interview at the assessment date; the investigators did not assign or influence treatment. Women with documented mastectomy and breast reconstruction were classified in the reconstruction group, women with documented mastectomy and no reconstruction were classified in the mastectomy-without-reconstruction group, and women with no documented mastectomy were classified in the non-mastectomy comparison group. Detailed local-treatment pathways in the comparison group were not consistently recorded, so this group should not be interpreted as a uniform breast-conserving-surgery cohort. Reconstruction timing (immediate or delayed) was also not consistently documented and could not be examined. The design was selected to compare psychological outcomes across the three groups and to examine contemporaneous associations among surgical status, body-image domains, sociodemographic and clinical characteristics, and self-esteem.
The study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. These guidelines were followed to improve transparency in reporting the study design, participant selection, variables, measurement procedures, statistical methods, and potential sources of bias (Cuschieri, 2019).
Study setting and participant recruitment
Participants were recruited consecutively from oncology centres, breast surgery clinics, and specialist oncology practices across several Iraqi governorates. Consecutive recruitment was intended to reduce convenience sampling and improve sample diversity; nevertheless, participation and access to particular surgical options may still have introduced selection effects.
The participant recruitment process is summarised in Figure 1. A total of 512 women with breast cancer were screened for eligibility. Of these, 62 were excluded: 18 did not meet the eligibility criteria, 21 declined participation, 14 returned substantially incomplete questionnaires, and 9 had insufficient clinical information in their medical records. The final analytical sample comprised 450 participants, including 150 women who underwent mastectomy with breast reconstruction, 150 women who underwent mastectomy without reconstruction, and 150 women in the non-mastectomy comparison group.
Figure 1.
Flow diagram of participant recruitment and study inclusion.
Eligibility criteria
Women were eligible for inclusion if they were aged 18–70 years, had a histologically confirmed diagnosis of breast cancer, and were able to complete the questionnaire independently. The lower age limit ensured that all participants were adults capable of providing informed consent, while the upper age limit was applied to reduce potential confounding from advanced age-related frailty, cognitive decline, and comorbidities that may independently influence body image, psychological well-being, and self-esteem. Histological confirmation of breast cancer was required to ensure diagnostic accuracy and avoid disease misclassification. Independent questionnaire completion was required because the study outcomes were patient-reported psychological constructs, and interviewer-assisted responses could increase social desirability bias or alter responses to sensitive questions related to body image and self-worth.
Pregnant women were excluded because pregnancy is independently associated with hormonal changes, altered breast perception, body image fluctuation, and emotional changes that could confound the relationship between breast cancer treatment and psychological outcomes. Women with documented cognitive impairment were excluded because impaired comprehension may reduce the reliability of self-reported responses. Patients with active psychiatric disorders that interfered with participation were excluded because severe psychiatric symptoms may independently affect self-esteem and body image, making it difficult to distinguish treatment-related psychological effects. Women unable to communicate in Arabic were excluded because the study instruments were administered using culturally adapted Arabic versions. Participants with substantially incomplete questionnaire or clinical data were excluded to preserve the validity of scale scoring, psychometric testing, and multivariable analyses.
Sample size calculation
Sample size estimation was performed a priori using G*Power version 3.1. The calculation was based on a one-way analysis of variance model involving three independent groups because the primary comparison involved self-esteem and body image outcomes across three clinical groups. Assuming a medium effect size of 0.25, a two-sided significance level of 0.05, and statistical power of 80%, the minimum required sample size was 252 participants (Kang, 2021). A larger sample of 450 participants was recruited to improve statistical precision, enhance the reliability of psychometric analyses, support adjustment for sociodemographic and clinical covariates, and allow more stable multivariable and mediation modelling. Equal allocation of 150 participants per group was used to maximise statistical efficiency and facilitate balanced comparisons across surgical categories.
Data collection procedures
After written informed consent was obtained, participants completed a structured Arabic questionnaire in a private clinical setting during routine oncology visits. Privacy was maintained during questionnaire completion because the study included sensitive questions related to appearance, self-perception, and social evaluation. Sociodemographic information was obtained directly from participants, while clinical information was collected through patient interview and medical record review to improve accuracy and reduce recall bias.
Sociodemographic variables included age, ethnicity, educational attainment, marital status, employment status, monthly household income, and number of children. Clinical variables included cancer stage, time since diagnosis, time since mastectomy where applicable, menopausal status, current chemotherapy exposure, radiotherapy history, hormonal therapy status, reconstruction type, recurrence history, and comorbidity burden. Reconstruction timing (immediate or delayed) and postoperative complication data were not consistently available and therefore could not be examined or included as covariates. The selected variables were considered because disease burden, treatment exposure, socioeconomic circumstances, recurrence, and surgical characteristics may be associated with both access to reconstruction and psychological outcomes.
Translation and cultural adaptation of instruments
The original study instruments were developed in English; therefore, Arabic versions were prepared using a forward-backward translation and cultural adaptation procedure based on internationally accepted recommendations for adapting self-report measures across languages and cultures (Sousa & Rojjanasrirat, 2011). This process was necessary because direct translation alone may not preserve the conceptual meaning of psychological constructs such as self-esteem, attractiveness, appearance investment, and fear of negative evaluation across different sociocultural contexts.
Two independent bilingual translators whose native language was Arabic translated the English questionnaires into Arabic. The two forward translations were compared and synthesised into a single preliminary Arabic version by the research team. Two additional bilingual translators, blinded to the original instruments, then independently back-translated the Arabic version into English. The original English instruments and the back-translated versions were compared to identify discrepancies, ambiguous wording, or culturally inappropriate expressions. Differences were resolved by consensus among the translators and research team, with emphasis placed on conceptual equivalence rather than literal translation.
The pre-final Arabic questionnaire was pilot tested among 30 women with breast cancer who were not included in the final analysis. Pilot testing was conducted to evaluate clarity, readability, cultural acceptability, item interpretation, and completion time. Feedback from the pilot group was reviewed, and minor wording modifications were made to improve comprehension while preserving the original meaning of the instruments. The finalised Arabic version was subsequently used in the main study. Details of the translation, cultural adaptation, pilot testing, and psychometric evaluation are provided in Supplementary Tables S1–S4.
Self-esteem assessment
Self-esteem was assessed using the Rosenberg Self-Esteem Scale, a widely used measure of global self-worth and self-acceptance (Gnambs et al., 2018). The scale contains 10 items rated on a four-point response format. Negatively worded items were reverse-scored, and item scores were summed to produce a total score ranging from 10 to 40, with higher scores indicating greater self-esteem.
The Rosenberg Self-Esteem Scale was selected because it is theoretically grounded in Rosenberg’s conceptualisation of global self-worth, has been extensively used across cultural and clinical populations, and is suitable for assessing self-evaluation among individuals experiencing major illness-related and appearance-related changes. In the context of breast cancer, global self-esteem is clinically relevant because altered appearance, treatment burden, concerns about femininity, and changes in intimate or social functioning may influence how women evaluate themselves.
Body image and appearance-related assessment
Appearance Evaluation and Appearance Orientation were assessed using the corresponding subscales of the Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS) developed by Cash (2000). Appearance Evaluation contains 7 items and assesses satisfaction with and perceived attractiveness of one's appearance. Appearance Orientation contains 12 items and assesses attention to, investment in, and behavioural management of appearance. Responses were obtained using the instruments' five-category format. For the analyses reported in this study, responses were subsequently recoded according to the prespecified study scoring key (0 or 1 per item, with reverse-scoring where required) and summed. Possible scores were therefore 0–7 for Appearance Evaluation and 0–12 for Appearance Orientation; higher scores indicated more favourable appearance evaluation and greater appearance orientation, respectively.
Fear of Negative Appearance Evaluation was assessed separately using the six-item Fear of Negative Appearance Evaluation Scale rather than an MBSRQ domain (Lundgren et al., 2004; Maïano et al., 2010). Items were answered using a five-category format ranging from low to high endorsement. Consistent with the study protocol, the same prespecified binary item-scoring approach was applied before summation, producing a possible score of 0–6; higher scores indicated greater concern about unfavourable appearance-based judgement by others.
The three measures were selected to distinguish related but non-equivalent processes: cognitive-affective satisfaction with appearance, behavioural investment in appearance, and social-evaluative concern. This distinction is relevant because women may report similar overall appearance satisfaction while differing in appearance salience, self-presentation behaviours, or fear of judgement (Quittkat et al., 2019). The item composition and scoring direction used in the main analysis are reflected consistently in the supplementary psychometric tables.
Psychometric evaluation
The reliability and construct validity of the Arabic versions were evaluated before hypothesis testing because the instruments were originally developed in English and were administered in an Arabic-speaking breast cancer population. The measurement model included the 10 Rosenberg items, 7 Appearance Evaluation items, 12 Appearance Orientation items, and 6 Fear of Negative Appearance Evaluation items.
Internal consistency was assessed using Cronbach's alpha and McDonald's omega. Cronbach's alpha was retained as a familiar index, while omega was also reported because it does not require equal item loadings (Hayes & Coutts, 2020; Taber, 2018). Values of 0.70 or higher were considered acceptable for group-level research.
Construct validity was examined using confirmatory factor analysis with maximum likelihood estimation. Model fit was evaluated using the Comparative Fit Index, Tucker-Lewis Index, Root Mean Square Error of Approximation, and Standardised Root Mean Square Residual. Comparative Fit Index and Tucker-Lewis Index values above 0.90 and Root Mean Square Error of Approximation and Standardised Root Mean Square Residual values below 0.08 were interpreted as acceptable (Kline, 2023). Reliability, convergent validity, factor loadings, and model-fit results are reported in Supplementary Tables S2–S4 and correspond to the item composition described above.
Statistical analysis
Data analysis was performed using IBM SPSS Statistics version 28 and IBM AMOS version 28. Continuous variables were summarised using means and standard deviations, while categorical variables were reported as frequencies and percentages. Normality was assessed using histograms, Q-Q plots, skewness, kurtosis, and the Shapiro-Wilk test because reliance on a single normality test may be misleading in large samples. Homogeneity of variance was assessed using Levene’s test.
Sociodemographic and clinical characteristics were compared across the three study groups using chi-square tests for categorical variables and one-way analysis of variance for continuous variables. These comparisons were performed to describe the sample and identify potential baseline differences that could confound the relationship between surgical group and psychological outcomes.
Differences in self-esteem and body image outcomes among the three groups were first assessed using one-way analysis of variance. Bonferroni-adjusted post hoc comparisons were then conducted to identify pairwise group differences while controlling for inflation of type I error due to multiple comparisons. Effect sizes were reported using partial eta-squared for overall group differences and Cohen’s d for pairwise comparisons because statistical significance alone does not indicate the magnitude or clinical relevance of observed differences.
Analysis of covariance was subsequently performed to adjust for potential confounding variables. Adjusted models included age, marital status, educational attainment, monthly household income, cancer stage, menopausal status, time since diagnosis, chemotherapy exposure, radiotherapy history, hormonal therapy status, recurrence history, and comorbidity burden. These variables were included because they may influence both surgical treatment patterns and psychological outcomes. Adjusted analyses were therefore necessary to determine whether group differences in self-esteem and body image persisted after accounting for relevant sociodemographic and clinical factors.
Pearson correlation analysis was used to examine associations between body-image domains and self-esteem. Hierarchical multiple linear regression was then performed, entering sociodemographic variables in the first block, clinical variables in the second, surgical group in the third, and body-image domains in the final block. Model R2, adjusted R2, changes in R2, standardised coefficients, and p-values were reported. For the fully adjusted coefficient table, bias-corrected 95% bootstrap confidence intervals for standardised coefficients were generated from 5,000 resamples. Multicollinearity was assessed using variance inflation factors, with values below 5 considered acceptable.
An exploratory cross-sectional indirect-effect analysis was performed using 5,000 bootstrap resamples. Because surgical status had three categories, a prespecified ordered contrast was used (0 = non-mastectomy comparison group, 1 = mastectomy with reconstruction, and 2 = mastectomy without reconstruction). This contrast estimated a graded trend across the three groups and was not intended to replace pairwise clinical comparisons. Direct, indirect, and total effects were estimated for the body-image variables, with indirect effects considered statistically detectable when the 95% bootstrap confidence interval excluded zero. Because surgical status, body-image measures, and self-esteem were assessed at the same time, these estimates were interpreted as statistical indirect associations and not as evidence of temporal or causal mediation.
Multivariable logistic regression was additionally used to identify factors associated with low self-esteem. Low self-esteem was operationalized as a Rosenberg score within the lowest quartile of this study sample. This sample-defined threshold was used for exploratory risk classification and should not be interpreted as a validated clinical cut-off. Adjusted odds ratios and 95% confidence intervals were reported. A two-sided p-value below 0.05 was considered statistically significant.
Results
Sociodemographic characteristics of the study population
The sociodemographic characteristics of the study population are presented in Table 1. The sample comprised 150 women who underwent mastectomy with breast reconstruction, 150 women who underwent mastectomy without reconstruction, and 150 women in the non-mastectomy comparison group.
Table 1.
Sociodemographic characteristics of participants according to surgical group.
| Variable | Mastectomy with BR (n = 150) | Mastectomy without BR (n = 150) | Non-mastectomy comparison (n = 150) | Total (N = 450) | p-value |
|---|---|---|---|---|---|
| Age, years, mean ± SD | 47.8 ± 9.6 | 49.2 ± 10.1 | 46.5 ± 9.4 | 47.8 ± 9.8 | 0.061 |
| Age group, n (%) | 0.118 | ||||
| 18–35 years | 30 (20.0) | 26 (17.3) | 30 (20.0) | 86 (19.1) | |
| 36–55 years | 79 (52.7) | 84 (56.0) | 88 (58.7) | 251 (55.8) | |
| >55 years | 41 (27.3) | 40 (26.7) | 32 (21.3) | 113 (25.1) | |
| Ethnicity, n (%) | 0.172 | ||||
| Arab | 89 (59.3) | 94 (62.7) | 104 (69.3) | 287 (63.8) | |
| Kurdish | 61 (40.7) | 56 (37.3) | 46 (30.7) | 163 (36.2) | |
| Educational attainment, n (%) | 0.726 | ||||
| Below university degree | 71 (47.3) | 65 (43.3) | 64 (42.7) | 200 (44.4) | |
| University degree or higher | 79 (52.7) | 85 (56.7) | 86 (57.3) | 250 (55.6) | |
| Marital status, n (%) | 0.018 | ||||
| Single | 30 (20.0) | 25 (16.7) | 36 (24.0) | 91 (20.2) | |
| Married | 80 (53.3) | 79 (52.7) | 72 (48.0) | 231 (51.3) | |
| Divorced | 16 (10.7) | 35 (23.3) | 18 (12.0) | 69 (15.3) | |
| Widowed | 24 (16.0) | 11 (7.3) | 24 (16.0) | 59 (13.1) | |
| Monthly household income, n (%) | 0.007 | ||||
| Low | 49 (32.7) | 54 (36.0) | 34 (22.7) | 137 (30.4) | |
| Average | 73 (48.7) | 81 (54.0) | 79 (52.7) | 233 (51.8) | |
| High | 28 (18.7) | 15 (10.0) | 37 (24.7) | 80 (17.8) | |
| Employment status, n (%) | 0.084 | ||||
| Employed | 58 (38.7) | 49 (32.7) | 66 (44.0) | 173 (38.4) | |
| Unemployed/housewife | 92 (61.3) | 101 (67.3) | 84 (56.0) | 277 (61.6) | |
| Number of children, mean ± SD | 3.1 ± 1.8 | 3.4 ± 1.9 | 2.9 ± 1.7 | 3.1 ± 1.8 | 0.072 |
BR, breast reconstruction; SD, standard deviation.
p-values were calculated using one-way analysis of variance for continuous variables and chi-square tests for categorical variables.
As shown in Table 1, the mean age of participants was comparable across the three groups, ranging from 46.5 ± 9.4 to 49.2 ± 10.1 years, with no statistically significant difference observed (p = 0.061). Educational attainment was similarly balanced, with more than half of participants in each group having a university degree or higher (52.7–57.3%, p = 0.726). Employment status and number of children also did not differ significantly between groups (all p > 0.05), suggesting a generally comparable sociodemographic profile.
However, significant differences were observed for marital status and monthly household income (Table 1). The proportion of divorced women was highest among participants who underwent mastectomy without breast reconstruction (23.3%) compared with those who underwent breast reconstruction (10.7%) and those who had not undergone mastectomy (12.0%) (p = 0.018). Significant differences were also observed in household income distribution (p = 0.007). Women in the non-mastectomy comparison group were more likely to report high household income (24.7%) compared with women who underwent breast reconstruction (18.7%) and women who underwent mastectomy without reconstruction (10.0%).
Because marital status and socioeconomic status differed significantly across study groups and have previously been associated with psychological adaptation, body image perception, and self-esteem among breast cancer survivors, these variables were subsequently included as covariates in adjusted analyses.
Clinical characteristics of the study population
The clinical characteristics of the participants are presented in Table 2. Several clinically important differences were observed across the three study groups.
Table 2.
Clinical characteristics of participants according to surgical group.
| Variable | Mastectomy with BR (n = 150) | Mastectomy without BR (n = 150) | Non-mastectomy comparison (n = 150) | Total (N = 450) | p-value* |
|---|---|---|---|---|---|
| Time since diagnosis (years), mean ± SD | 3.8 ± 2.1 | 4.5 ± 2.6 | 2.9 ± 1.8 | 3.7 ± 2.3 | <0.001 |
| Cancer stage, n (%) | 0.003 | ||||
| Stage I | 38 (25.3) | 21 (14.0) | 57 (38.0) | 116 (25.8) | |
| Stage II | 73 (48.7) | 67 (44.7) | 62 (41.3) | 202 (44.9) | |
| Stage III | 34 (22.7) | 52 (34.7) | 26 (17.3) | 112 (24.9) | |
| Stage IV | 5 (3.3) | 10 (6.7) | 5 (3.3) | 20 (4.4) | |
| Menopausal status, n (%) | 0.011 | ||||
| Premenopausal | 84 (56.0) | 67 (44.7) | 91 (60.7) | 242 (53.8) | |
| Postmenopausal | 66 (44.0) | 83 (55.3) | 59 (39.3) | 208 (46.2) | |
| Current chemotherapy, n (%) | 49 (32.7) | 63 (42.0) | 38 (25.3) | 150 (33.3) | 0.009 |
| Previous radiotherapy, n (%) | 89 (59.3) | 95 (63.3) | 68 (45.3) | 252 (56.0) | 0.004 |
| Hormonal therapy exposure, n (%) | 96 (64.0) | 102 (68.0) | 81 (54.0) | 279 (62.0) | 0.027 |
| Recurrence history, n (%) | 18 (12.0) | 36 (24.0) | 12 (8.0) | 66 (14.7) | <0.001 |
| Reconstruction type*, n (%) | |||||
| Implant-based | 92 (61.3) | − | − | 92 (61.3) | |
| Autologous | 58 (38.7) | − | − | 58 (38.7) | |
| Charlson comorbidity score, mean ± SD | 1.2 ± 0.8 | 1.5 ± 1.0 | 1.1 ± 0.7 | 1.3 ± 0.8 | 0.018 |
Evaluated only among women who underwent breast reconstruction.
As shown in Table 2, women who underwent mastectomy without breast reconstruction had the longest mean duration since diagnosis (4.5 ± 2.6 years), whereas the non-mastectomy comparison group had the shortest duration (2.9 ± 1.8 years) (p < 0.001). Cancer-stage distribution also differed (p = 0.003); stage III disease was more common in the mastectomy-without-reconstruction group (34.7%) than in the reconstruction group (22.7%) or non-mastectomy comparison group (17.3%).
Menopausal status differed significantly between groups (p = 0.011). Postmenopausal women represented more than half of participants who underwent mastectomy without reconstruction (55.3%), compared with 44.0% in the reconstruction group and 39.3% in the non-mastectomy comparison group. Similarly, significant differences were observed in current chemotherapy exposure (42.0% vs. 32.7% vs. 25.3%, p = 0.009), previous radiotherapy (63.3% vs. 59.3% vs. 45.3%, p = 0.004), and hormonal therapy exposure (68.0% vs. 64.0% vs. 54.0%, p = 0.027).
Notably, recurrence history differed substantially across groups (p < 0.001). Women who underwent mastectomy without reconstruction demonstrated the highest prevalence of recurrent disease (24.0%), approximately twice that observed among women who underwent breast reconstruction (12.0%) and three times that observed in the non-mastectomy comparison group (8.0%).
Taken together, these findings indicate that women who underwent mastectomy without reconstruction generally exhibited less favourable clinical profiles, including more advanced disease, greater treatment exposure, and a higher burden of recurrent disease. Because these characteristics may independently influence psychological adjustment, body image, and self-esteem, they were included as covariates in subsequent adjusted analyses.
Group differences in self-esteem and body image
Group differences in self-esteem and body image outcomes are presented in Table 3. Significant unadjusted differences were observed across the three study groups for self-esteem, appearance evaluation, appearance orientation, and fear of negative appearance evaluation (all p < 0.001).
Table 3.
Unadjusted and adjusted comparisons of self-esteem and body image outcomes across surgical groups.
| Outcome | Mastectomy with BR (n = 150), mean ± SD | Mastectomy without BR (n = 150), mean ± SD | Non-mastectomy comparison (n = 150), mean ± SD | Unadjusted p-value | Adjusted p-value* | Partial η2 |
|---|---|---|---|---|---|---|
| Self-esteem | 32.9 ± 5.1 | 26.7 ± 5.8 | 37.4 ± 4.2 | <0.001 | <0.001 | 0.41 |
| Appearance Evaluation | 3.21 ± 1.04 | 3.25 ± 1.10 | 5.63 ± 0.91 | <0.001 | <0.001 | 0.48 |
| Appearance Orientation | 8.72 ± 1.58 | 9.53 ± 1.42 | 6.11 ± 1.63 | <0.001 | <0.001 | 0.36 |
| Fear of Negative Appearance Evaluation | 4.97 ± 0.86 | 4.56 ± 0.92 | 2.48 ± 0.81 | <0.001 | <0.001 | 0.52 |
BR, breast reconstruction; SD, standard deviation.
Adjusted for age, marital status, monthly household income, cancer stage, menopausal status, time since diagnosis, chemotherapy exposure, radiotherapy history, hormonal therapy exposure, recurrence history, and Charlson comorbidity score.
As shown in Table 3, women who underwent mastectomy without breast reconstruction had the lowest mean self-esteem score (26.7 ± 5.8), followed by women who underwent mastectomy with breast reconstruction (32.9 ± 5.1), while the non-mastectomy comparison group reported the highest score (37.4 ± 4.2) (p < 0.001). Appearance Evaluation was similarly low in both mastectomy groups (3.21 ± 1.04 with reconstruction and 3.25 ± 1.10 without reconstruction) and higher in the non-mastectomy comparison group (5.63 ± 0.91) (p < 0.001).
Appearance Orientation also differed significantly across groups (p < 0.001). Women who underwent mastectomy without reconstruction reported the highest score (9.53 ± 1.42), followed by women with reconstruction (8.72 ± 1.58), whereas the non-mastectomy comparison group reported the lowest score (6.11 ± 1.63). Fear of Negative Appearance Evaluation was higher in both mastectomy groups and was slightly higher in the reconstruction group (4.97 ± 0.86) than in the group without reconstruction (4.56 ± 0.92); the non-mastectomy comparison group reported the lowest score (2.48 ± 0.81) (p < 0.001).
After adjustment for age, marital status, monthly household income, cancer stage, menopausal status, time since diagnosis, chemotherapy exposure, radiotherapy history, hormonal therapy exposure, recurrence history, and comorbidity burden, the differences in self-esteem and body image outcomes remained statistically significant (all adjusted p < 0.001). These findings indicate that the observed psychological differences were not fully explained by sociodemographic or clinical imbalances between groups.
Figure 2 illustrates adjusted mean self-esteem scores across the three groups. Women who underwent mastectomy without breast reconstruction had the lowest adjusted score, the non-mastectomy comparison group had the highest score, and women with reconstruction occupied an intermediate position. This descriptive adjusted pattern does not establish that reconstruction caused the observed difference.
Figure 2.
Adjusted mean self-esteem scores across surgical groups.
Associations between body image domains and self-esteem
Pearson correlation coefficients between self-esteem and body image domains are presented in Table 4. Significant associations were observed between all body image dimensions and self-esteem.
Table 4.
Pearson correlations among body image domains and self-esteem.
| Variable | 1 | 2 | 3 | 4 |
|---|---|---|---|---|
| 1. Self-esteem | 1 | |||
| 2. Appearance Evaluation | 0.68*** | 1 | ||
| 3. Appearance Orientation | −0.29*** | −0.22*** | 1 | |
| 4. Fear of Negative Appearance Evaluation | −0.61*** | −0.55*** | 0.31*** | 1 |
***p < 0.001.
As shown in Table 4, appearance evaluation demonstrated the strongest positive association with self-esteem (r = 0.68, p < 0.001), indicating that women who reported greater satisfaction with their physical appearance also tended to report higher levels of self-worth. Appearance orientation showed a weaker but significant negative association with self-esteem (r = −0.29, p < 0.001), suggesting that excessive investment in appearance may be associated with reduced psychological well-being.
Fear of negative appearance evaluation was negatively associated with self-esteem (r = −0.61, p < 0.001). Women who expressed greater concern regarding appearance-based judgement by others tended to report substantially lower self-esteem. Moderate correlations were also observed among the body image domains themselves, supporting their conceptual relatedness while indicating that they represent distinct psychological constructs.
Overall, appearance evaluation and fear of negative appearance evaluation demonstrated the strongest relationships with self-esteem and were therefore expected to contribute substantially to subsequent multivariable models.
Independent predictors of self-esteem
To identify factors independently associated with self-esteem, hierarchical multiple linear regression analysis was performed (Table 5). Sociodemographic variables were entered in Model 1, clinical variables in Model 2, surgical group in Model 3, and body image domains in Model 4.
Table 5.
Hierarchical regression model summary for predictors of self-esteem.
| Model | Variables entered | R2 | Adjusted R2 | ΔR2 | F change | p-value |
|---|---|---|---|---|---|---|
| Model 1 | Sociodemographic variables | 0.09 | 0.08 | 0.09 | 6.12 | <0.001 |
| Model 2 | Model 1 + clinical variables | 0.20 | 0.18 | 0.11 | 8.93 | <0.001 |
| Model 3 | Model 2 + surgical group | 0.28 | 0.26 | 0.08 | 11.47 | <0.001 |
| Model 4 | Model 3 + body image domains | 0.60 | 0.58 | 0.32 | 39.58 | <0.001 |
Model 1 included age, educational attainment, marital status, household income, and employment status.
Model 2 additionally included cancer stage, time since diagnosis, menopausal status, chemotherapy exposure, radiotherapy history, hormonal therapy exposure, and recurrence history.
Model 3 additionally included surgical group.
Model 4 additionally included appearance evaluation, appearance orientation, and fear of negative appearance evaluation.
To provide detailed estimates from the final regression model, standardised coefficients and confidence intervals for all variables are presented in Table 6.
Table 6.
Fully adjusted hierarchical regression model identifying independent predictors of self-esteem.
| Predictor | Standardised β | Bias-corrected bootstrap 95% CI | p-value |
|---|---|---|---|
| Age | −0.03 | −0.10 to 0.05 | 0.482 |
| University education | 0.04 | −0.04 to 0.12 | 0.318 |
| Married status | 0.04 | −0.03 to 0.12 | 0.294 |
| Household income | 0.10 | 0.02 to 0.18 | 0.018 |
| Employment status | 0.03 | −0.05 to 0.10 | 0.517 |
| Cancer stage | −0.04 | −0.12 to 0.04 | 0.337 |
| Time since diagnosis | 0.03 | −0.05 to 0.10 | 0.468 |
| Menopausal status | −0.05 | −0.13 to 0.03 | 0.226 |
| Chemotherapy exposure | −0.04 | −0.12 to 0.04 | 0.326 |
| Radiotherapy history | −0.03 | −0.10 to 0.05 | 0.489 |
| Hormonal therapy exposure | −0.06 | −0.14 to 0.02 | 0.143 |
| Recurrence history | −0.11 | −0.20 to −0.03 | 0.012 |
| Mastectomy with BR | −0.05 | −0.13 to 0.04 | 0.286 |
| Mastectomy without BR | −0.09 | −0.18 to 0.01 | 0.071 |
| Appearance Evaluation | 0.46 | 0.39 to 0.53 | <0.001 |
| Appearance Orientation | −0.09 | −0.17 to −0.01 | 0.041 |
| Fear of Negative Appearance Evaluation | −0.34 | −0.42 to −0.27 | <0.001 |
BR, breast reconstruction; CI, confidence interval. Reference group for surgical status: non-mastectomy comparison group. Confidence intervals are bias-corrected 95% bootstrap intervals for standardised coefficients based on 5,000 resamples. Final model R2 = 0.60; adjusted R2 = 0.58.
As shown in Table 5, sociodemographic variables explained a modest proportion of variance in self-esteem (Model 1, R2 = 0.09). Among these variables, higher household income emerged as a significant positive predictor of self-esteem (β = 0.18, p = 0.002), whereas age, educational attainment, marital status, and employment status were not independently associated with self-esteem.
The addition of clinical variables in Model 2 significantly improved model performance (ΔR2 = 0.11, p < 0.001). Recurrence history was independently associated with lower self-esteem (β = −0.22, p < 0.001), while hormonal therapy exposure demonstrated a modest negative association with self-esteem (β = −0.11, p = 0.028). Cancer stage, menopausal status, chemotherapy exposure, radiotherapy history, and time since diagnosis were not significant independent predictors after adjustment.
In Model 3, surgical status contributed additional explanatory value (ΔR2 = 0.08, p < 0.001). Relative to the non-mastectomy comparison group, both mastectomy categories were associated with lower self-esteem before body-image domains were entered, with a larger standardised coefficient for mastectomy without reconstruction (β = −0.25, p < 0.001) than for mastectomy with reconstruction (β = −0.12, p = 0.019).
The final model, which incorporated body-image domains, had an unadjusted coefficient of determination of R2 = 0.60 and an adjusted R2 = 0.58. Thus, the predictors collectively accounted for 60% of the observed variance, while the estimate adjusted for model complexity was 58%. Appearance Evaluation was the strongest positive correlate (β = 0.46, p < 0.001), and Fear of Negative Appearance Evaluation was the strongest negative correlate (β = −0.34, p < 0.001). Appearance Orientation showed a smaller negative association (β = −0.09, p = 0.041).
The surgical-status coefficients were attenuated after body-image domains were added to the model. In this cross-sectional analysis, the attenuation indicates statistical overlap between surgical status, body-image scores, and self-esteem; it does not establish a temporal psychological mechanism.
Exploratory cross-sectional indirect-effect analysis
An exploratory analysis examined statistical indirect associations of body-image domains between the ordered surgical-status contrast and self-esteem. The contrast was coded 0 for the non-mastectomy comparison group, 1 for mastectomy with reconstruction, and 2 for mastectomy without reconstruction. Direct, indirect, and total effects are presented in Table 7.
Table 7.
Exploratory cross-sectional indirect-effect analysis of body-image domains in the association between the ordered surgical-status contrast and self-esteem.
| Mediator | Direct effect β (95% CI) | Indirect effect β (95% CI) | Total effect β (95% CI) | % mediated |
|---|---|---|---|---|
| Appearance Evaluation | −0.07 (−0.16, 0.02) | −0.21 (−0.29, −0.14) | −0.28 (−0.37, −0.20) | 75.0 |
| Appearance Orientation | −0.24 (−0.33, −0.15) | −0.04 (−0.08, −0.01) | −0.28 (−0.36, −0.20) | 14.3 |
| Fear of Negative Appearance Evaluation | −0.13 (−0.22, −0.04) | −0.15 (−0.22, −0.09) | −0.28 (−0.36, −0.20) | 53.6 |
| Combined mediation model | −0.03 (−0.11, 0.05) | −0.25 (−0.34, −0.18) | −0.28 (−0.37, −0.20) | 89.0 |
CI, confidence interval. Bootstrap estimates were based on 5,000 resamples. Surgical-status contrast: 0 = non-mastectomy comparison group, 1 = mastectomy with reconstruction, and 2 = mastectomy without reconstruction.
Indirect effects were considered statistically detectable when the 95% bootstrap confidence interval excluded zero. The percentage accounted for is descriptive and does not imply causal or temporal mediation.
Statistically detectable indirect effects were observed for all three body-image domains. Appearance Evaluation had the largest individual indirect effect (β = −0.21, 95% bootstrap CI: −0.29 to −0.14), indicating that poorer appearance evaluation statistically accounted for part of the association represented by the ordered surgical-status contrast.
Fear of Negative Appearance Evaluation also showed a detectable indirect effect (β = −0.15, 95% bootstrap CI: −0.22 to −0.09). The indirect effect for Appearance Orientation was smaller (β = −0.04, 95% bootstrap CI: −0.08 to −0.01). These estimates describe contemporaneous statistical associations and should not be interpreted as temporal pathways.
In the combined model, the indirect effect through the body-image domains was β = −0.25 (95% bootstrap CI: −0.34 to −0.18), statistically accounting for approximately 89% of the total association represented by the ordered contrast. The direct effect was attenuated and not statistically detectable after inclusion of the body-image variables (β = −0.03, 95% CI: −0.11 to 0.05).
Predictors of low self-esteem
A multivariable logistic regression analysis was conducted to identify factors independently associated with low self-esteem, defined as a Rosenberg score within the lowest quartile of this sample. The threshold was exploratory rather than a validated clinical cut-off. Results are presented in Table 8.
Table 8.
Multivariable logistic regression analysis identifying predictors of low self-esteem.
| Predictor | Adjusted OR | 95% CI | p-value |
|---|---|---|---|
| Age | 1.02 | 0.98–1.06 | 0.318 |
| Low household income | 1.56 | 1.02–2.39 | 0.041 |
| Postmenopausal status | 1.21 | 0.78–1.88 | 0.392 |
| Current chemotherapy | 1.34 | 0.86–2.08 | 0.196 |
| Hormonal therapy exposure | 1.29 | 0.84–1.98 | 0.247 |
| Recurrence history | 2.18 | 1.29–3.68 | 0.004 |
| Mastectomy with BR | 1.28 | 0.76–2.16 | 0.348 |
| Mastectomy without BR | 1.62 | 0.96–2.72 | 0.071 |
| Appearance Evaluation | 0.42 | 0.31–0.57 | <0.001 |
| Appearance Orientation | 1.19 | 1.02–1.39 | 0.028 |
| Fear of Negative Appearance Evaluation | 2.74 | 1.91–3.92 | <0.001 |
BR, breast reconstruction; CI, confidence interval; OR, odds ratio. The reference group for surgical status was the non-mastectomy comparison group. Low self-esteem was defined using the sample-specific lowest quartile and is not a validated clinical threshold.
As shown in Table 8, recurrence history was independently associated with higher odds of low self-esteem (adjusted OR = 2.18, 95% CI: 1.29–3.68, p = 0.004). Fear of negative appearance evaluation was also strongly associated with increased odds of low self-esteem (adjusted OR = 2.74, 95% CI: 1.91–3.92, p < 0.001). In contrast, higher appearance evaluation was protective against low self-esteem (adjusted OR = 0.42, 95% CI: 0.31–0.57, p < 0.001).
After adjustment for sociodemographic, clinical, and body-image variables, surgical status was not independently associated with the sample-defined low-self-esteem outcome. This pattern indicates that body-image measures carried stronger adjusted associations in this dataset, but it does not establish that surgical category is psychologically unimportant or that body image causally precedes self-esteem.
Discussion
This study compared self-esteem and appearance-related outcomes across three surgical-status groups in an Iraqi breast cancer sample. Women who underwent mastectomy without reconstruction reported the lowest self-esteem, women with reconstruction reported intermediate scores, and the non-mastectomy comparison group reported the highest scores. Appearance Evaluation and Fear of Negative Appearance Evaluation showed the strongest adjusted associations with self-esteem. The exploratory indirect-effect analysis further showed substantial statistical overlap among surgical status, body-image measures, and self-esteem, while recurrence history remained independently associated with poorer self-esteem.
The group comparisons require careful interpretation because surgical and reconstructive treatments were not randomly assigned. Women in the three groups differed in cancer stage, recurrence history, household income, menopausal status, treatment exposure, comorbidity burden, and time since diagnosis. These differences may reflect confounding by indication, access to reconstruction, patient preference, clinician selection, or disease severity. Although the adjusted analyses accounted for measured characteristics, residual confounding and treatment-selection effects cannot be excluded. This qualification is especially important when comparing reconstruction with no reconstruction in an observational study (Álvarez-Pardo et al., 2023; Latifee et al., 2025).
The self-esteem pattern was nevertheless substantial at the descriptive level. Mean Rosenberg scores differed by 6.2 points between the two mastectomy groups and by 10.7 points between mastectomy without reconstruction and the non-mastectomy comparison group. The large partial eta-squared values in Table 3 indicate sizeable between-group differences within this sample, although a validated minimal clinically important difference is not available for every adapted measure used here. The results therefore support clinical attention to the magnitude of distress while avoiding the conclusion that reconstruction itself caused the higher self-esteem observed in the reconstructed group (Álvarez-Pardo et al., 2023; Latifee et al., 2025; Weingarden et al., 2022; Zehra et al., 2020).
The Iraqi and broader Middle Eastern context may also have shaped how participants interpreted and reported these experiences. Social expectations surrounding femininity, marriage, modesty, family roles, and the privacy of breast-related changes may influence the meaning attached to mastectomy, reconstruction, scarring, and perceived judgement by others. Family support and individual beliefs may either buffer or intensify distress. These cultural factors were not measured directly; therefore, the present findings should not be attributed to culture alone, and qualitative and longitudinal studies are needed to examine how cultural meanings interact with surgical experience and body image.
An important nuance was that Appearance Evaluation was nearly identical in the two mastectomy groups, whereas self-esteem was higher among women with reconstruction. This suggests that the difference in global self-worth was not reducible to appearance satisfaction alone. Other unmeasured factors may have contributed, including perceived bodily wholeness, intimacy, social support, sense of treatment completion, personal choice, coping style, or differences in clinical burden. The finding also reinforces the distinction between global self-esteem and specific appearance evaluations.
Fear of Negative Appearance Evaluation was slightly higher in the reconstruction group than in the mastectomy-without-reconstruction group. One possible interpretation is that women choosing reconstruction may place greater importance on appearance or may monitor symmetry, scarring, and social reactions more closely. High expectations for reconstruction, unmet cosmetic expectations, ongoing comparison with the pre-treatment body, and heightened attention to how others may evaluate the reconstructed breast could also contribute. These explanations remain hypotheses because expectations, satisfaction with surgical results, reconstruction timing, and postoperative complications were not consistently measured (Teo et al., 2018; Weingarden et al., 2022).
Appearance Evaluation and Fear of Negative Appearance Evaluation were the body-image variables most strongly associated with self-esteem. Their inclusion attenuated the surgical-status coefficients, and the combined exploratory model statistically accounted for approximately 89% of the total association represented by the ordered contrast. Because all variables were assessed cross-sectionally, this finding should be understood as a statistical indirect association rather than evidence that surgery first changed body image and body image subsequently changed self-esteem. The ordered contrast also summarises a graded group pattern and does not substitute for separate pairwise causal comparisons. Longitudinal research is required to establish temporal ordering and to test whether modifying body-image concerns improves self-esteem (Lewis-Smith et al., 2018; Mokhtari-Hessari & Montazeri, 2020; Sherman et al., 2018).
Recurrence history was independently associated with lower self-esteem and greater odds of the sample-defined low-self-esteem outcome. Recurrent disease may intensify uncertainty, fear of progression, repeated treatment burden, and disruption of future plans, all of which can affect psychological adjustment (Jiang et al., 2025; Tran et al., 2022; Yang et al., 2025). Hormonal therapy was associated with self-esteem in an earlier model but not after body-image domains were added. Endocrine-treatment symptoms, including menopausal symptoms, sexual difficulties, fatigue, and perceived bodily change, may be relevant to self-perception, although the present analysis cannot establish an indirect treatment pathway (Alnaim, 2022; Ferreira et al., 2019; McGrath & Roderick, 2025).
Clinically, the findings support routine enquiry about appearance satisfaction, appearance-related judgement, and self-esteem during survivorship care, particularly among women with recurrence or substantial treatment burden. Discussions about reconstruction should include realistic expectations and acknowledge that psychological responses vary. Psychoeducation, peer support, and referral to psycho-oncology or body-image-focused services may be appropriate where distress is identified. However, this study did not evaluate an intervention, so the effectiveness of these approaches should be tested prospectively rather than inferred from the observed associations.
Strengths include the balanced three-group sample, multicentre recruitment, adjustment for a broad set of sociodemographic and clinical variables, and evaluation of several distinct appearance-related constructs. The psychometric analyses also provided information on the reliability and factor structure of the Arabic measures, and the combination of group comparisons, hierarchical regression, indirect-effect analysis, and logistic regression offered complementary views of the data.
Several limitations should be considered. The cross-sectional design prevents temporal or causal inference, and reciprocal associations between body image and self-esteem are possible. Consecutive recruitment cannot eliminate non-participation, referral, or selection bias. Confounding by indication and access to reconstruction may persist despite adjustment. The non-mastectomy comparison group was heterogeneous because detailed local-treatment pathways were not consistently recorded. Reconstruction timing, postoperative complications, baseline expectations, surgical satisfaction, and social support were also unavailable. Self-reported measures may be affected by recall and social-desirability bias. The ordered coding used for the exploratory indirect-effect analysis simplifies a multicategorical clinical exposure, and the lowest-quartile definition of low self-esteem was sample-specific rather than clinically validated. Finally, the Iraqi cultural and healthcare setting may limit generalisability. Longitudinal and intervention studies are needed to evaluate change over time and test the clinical usefulness of targeted support.
Conclusion
Women who underwent mastectomy without reconstruction reported the lowest self-esteem and less favourable body-image profiles, women with reconstruction reported intermediate self-esteem, and the non-mastectomy comparison group reported the highest scores. Appearance Evaluation and Fear of Negative Appearance Evaluation were the factors most strongly associated with self-esteem and statistically accounted for much of the cross-sectional association represented by the surgical-status contrast. These findings support consideration of body-image and self-esteem assessment in survivorship care. However, intervention effectiveness was not evaluated in this study, and prospective trials are required to determine whether targeted psychosocial interventions improve self-esteem and related outcomes.
Supplementary Material
Supplementary Tables.docx
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
None.
Ethics statement
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Institutional Research Ethics Committee of Al Rafidain University College granted the ethical approval for this study (EC-69).
Data availability statement
Data and other materials are available upon request from the corresponding authors.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Consent to publish
Participants provided informed consent regarding the publication of their de-identified data.
Supplementary material
Supplemental data for this article can be accessed at https://doi.org/10.1080/21642850.2026.2721024.
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Supplementary Materials
Supplementary Tables.docx
Data Availability Statement
Data and other materials are available upon request from the corresponding authors.