Abstract
Breast cancer patients encounter body image changes throughout their diagnosis, treatment, and recovery from breast cancer. No prospective studies were identified investigating communication between physicians and breast cancer patients related to body image. This qualitative pilot study determines 1) how breast cancer patients prefer their physicians communicate regarding body image changes, and 2) how comfortable physicians are in discussing body image issues with their patients. Data was collected from patients over twelve weeks through the Breast Evaluation Questionnaire (BEQ), a valid and reliable instrument, and a qualitative questionnaire. Ten physicians completed a qualitative questionnaire. The data were analyzed using frequency analysis. Nearly seventy percent of the patients reported there was more the physician could do to improve patient comfort in discussing breast-related body image concerns. Honesty, openness, and directness were important to the patients. Thirty-three percent of the patients answered that their physicians should be honest, open, and direct discussing these issues. On a five point Likert scale (1= very uncomfortable and 5= very comfortable), the physicians most frequently answered a 4 when asked how comfortable they are speaking about breast-related body image issues, however, only four out of ten always address the topic themselves during the patient's visit. This data suggests that patients want honesty, openness, and directness from their physicians related to the discussion of breast-related body image issues. The physicians report they are comfortable speaking about breast-related body image issues; yet, they do not directly initiate the topic.
Background
A woman's appearance has shaped their femininity and sexuality throughout history. The size and shape of their breasts are a large part of that appearance. For a breast cancer patient this aspect of their appearance is changed forever after their treatment and recovery. This can lead to one of the many stressful situations they will encounter as breast cancer patients. One of the psychosocial stresses of breast cancer is breast-related body image stress (Helms et al). Many women have a difficult time dealing with their stress and as health care providers we need to be able to communicate with them to resolve their concerns. Breast-related body image issues can be a sensitive topic for breast cancer patients which can be alleviated when identified.
Many studies exist analyzing the patient-physician communication skills. We have learned how necessary it is for the patient to have positive interactions with their physician in order to heal physically and emotionally in all aspects of healthcare including breast cancer patients (Han et al). However, no study has investigated the communication between a physician and breast cancer patient in the context of body image. Revealing body image stress with the medical team is the first step in finding the correct care plan for the breast cancer patient's body image issues. This qualitative study will determine how physicians and nurses should communicate with their breast cancer patients so that the patients may feel at ease when addressing their breast-related body image issues.
Hypothesis
Breast cancer patients are reluctant to speak with their physicians about their breast-related body image issues and prefer their physicians initiate the subject. Physicians are uncomfortable approaching the subject of breast-related body image issues with breast cancer patients (Cohen et al).
Objectives
This pilot, qualitative study's objectives were to determine how breast cancer patients prefer their physicians communicate with them about breast-related body image issues; and how comfortable physicians are with communicating with their breast cancer patients about breast-related body image issues.
Methods
Data were collected in 2010 over twelve weeks from thirty-three breast cancer patients and ten physicians. The patients had early stage breast cancer (Stages 0, I, II, and III) and were within one year of their diagnosis of breast cancer. The physicians were Surgical Oncologists, Medical Oncologists, Radiation Oncologists, and Plastic Surgeons. The patients were given a Breast Evaluation Questionnaire (BEQ) and a qualitative questionnaire. The BEQ is a valid and reliable test for the subsets: Comfort not fully dressed, Comfort fully dressed, and Satisfaction with breast attributes (Anderson et al). The physicians were given a qualitative questionnaire asking about their comfort in communicating with their patients about breast-related body image issues. The data trends were examined and analyzed by the most frequent answers.
Results
The data suggests that there is more physicians can do to help their breast cancer patients be comfortable speaking with them about their breast-related body image issues. The patient demographics can be seen in Table 1. According to the data from the BEQ, forty-two percent of the patients were very comfortable with the appearance of their breasts while fully clothed while they were alone, but only twenty-seven percent of the patients were very comfortable with the appearance of their breasts while naked while they were alone. Only twelve percent of the patients were very satisfied with the general appearance of their breasts. Fifty-five percent of the patients ranked the size of their breasts as somewhat important or higher.
Table 1. Patient Demographics.
| N | Mean | Standard Deviation | |
|---|---|---|---|
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| |||
| Age | 33 | 50.39 | 11.60 |
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| |||
| Frequency | |||
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| Race | African American Caucasian Mexican | 7 (21%) | |
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| 25 (76%) | |||
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| 1 (3%) | |||
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| |||
| Breast Cancer Treatments Undergone | Surgery Chemotherapy Radiation Therapy Other | 22 (67%) | |
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|
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| 19 (58%) | |||
|
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| 6 (18%) | |||
|
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| 33 (100%) | |||
According to the data from the qualitative questionnaire nearly seventy percent of the patients felt that there was more their physicians could do. Table 2 shows thirty-three percent of the patients wanted their physicians to be open, honest, and direct when communicating about breast-related body image issues. The patients also recommended that medical students be direct and honest with their future patients to make them feel more comfortable communicating about breast-related body image issues.
Table 2. Patient Qualitative Questionnaire.
| Question | N | Mode | Median | Minimum | Maximum |
|---|---|---|---|---|---|
| Before being diagnosed with breast cancer, how important was your physical appearance on a scale of 1-5. Please check one answer. | 33 | 4.00 | 4.00 | 1.00 | 5.00 |
| After being diagnosed with breast cancer, how important is your physical appearance on a scale of 1-5? Please check one answer. | 33 | 4.00 | 4.00 | 1.00 | 5.00 |
| Before being diagnosed with breast cancer, how important was the appearance of your Breasts on a scale of 1-5? Please check one answer. | 33 | 4.00 | 4.00 | 2.00 | 5.00 |
| After being diagnosed with breast cancer, how important was the appearance of your Breasts on a scale of 1-5? Please check one answer. | 33 | 4.00 | 4.00 | 2.00 | 5.00 |
| How comfortable do you feel talking to your physicians about your breast-related body image issues on a scale of 1-5? Please check one answer. | 33 | 5.00 | 4.00 | 3.00 | 5.00 |
| How satisfied are you with your breast cancer treatments on a scale of 1-5? Please check one answer. | 33 | 5.00 | 5.00 | 3.00 | 5.00 |
| In what way could your physician make you more comfortable communicating your breast-related body image issues? | Frequency | ||||
| Be open and honest | 6 (18%) | ||||
| Be direct and start the conversation | 5 (15%) | ||||
| What advice would you give a medical student in helping women with breast cancer stay comfortable communicating their breast-related body image issues? | |||||
| Sympathize with the patient | 12 (36%) | ||||
| Be Direct and Honest | 8 (24%) | ||||
| Before your breast cancer diagnosis, were you concerned about breast-related body image issues? | |||||
| Yes | 17 (52%) | ||||
| No | 16 (48%) | ||||
| Since your breast cancer diagnosis, were you concerned about breast-related body image issues? | |||||
| Yes | 27 (82%) | ||||
| No | 6 (18%) | ||||
The physicians ranked that they were comfortable on a five point Likert scale (1= uncomfortable, 5= very comfortable) with speaking with their breast cancer patients about breast-related body image issues shown in Table 3. However, only four of the ten physicians always initiate the conversation (Cohen et al).
Table 3. Physician Qualitative Questionnaire.
| Do you ask your breast cancer patients about their breast-related body image issues? | Frequency | ||||
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| Yes | 4 | ||||
| Sometimes | 4 | ||||
| No | 2 | ||||
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| Do you wait for the breast cancer patients to bring up their breast-related body image issues or do you ask if they have any? | Frequency | ||||
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| Ask | 4 | ||||
| Wait | 3 | ||||
| Both | 3 | ||||
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| Question | N | Mode | Median | Minimum | Maximum |
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| How comfortable do you feel speaking with your breast cancer patients about their breast-related body image issues on a scale of 1-5? | 10 | 4.00 | 4.00 | 1.00 | 5.00 |
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| How do you phrase your question to discover if your breast cancer patient has any breast-related body image issues (How do you bring it up)? | Frequency | ||||
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| Ask about treatment | 6 | ||||
| Ask directly | 2 | ||||
| Allow patient to bring up the subject | 2 | ||||
| Other | 1 | ||||
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| What do you feel is the best way to address/explore breast related body image issues? | Frequency | ||||
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| Ask about treatment | 2 | ||||
| Ask directly | 2 | ||||
| Allow patient to bring up the subject | 1 | ||||
| Other | 6 | ||||
Application for Plastic Surgery Nurses
Given that these data demonstrates the importance of direct, open and honest communication between physicians and breast cancer patients related to breast associated body image, the plastic surgery nurse is in a uniquely valuable position to foster such communication. As an integral member of the treatment team the plastic surgery nurse may recognize the need for a discussion related to body image issues while providing patient education. The nurse might recognize that such communication is warranted and serve to bridge the communication between patient and physician or perhaps initially broach the subject her/him self. As an important member of the medical team, the plastic surgery nurse might educate the patient related to body image concerns, normalize feelings of the patient related to body image, and offer support to patients who are experiencing body image stress.
Some patients may not be forthcoming regarding their body image concerns, and prefer that the medical team initiate the discussion. This study identified specifics related to what the patients want or expect from their medical team. Responses to the BEQ identified that appearance of the breasts are very important to the patients, and while most had greater comfort with the appearance when fully clothed, satisfaction was greatly reduced while naked. Given this finding, the nurse might initiate the conversation by asking the patient about the level of comfort with the appearance of their breasts. Depending upon the response they could pursue issues related to body image adjustment and make appropriate referrals. The nurse is in a position to pass this information along to the physician or other providers who may then choose to address the issue further with their patient.
Conclusion
This data shows that breast cancer patients want their physicians to be open, honest, and direct when communicating with them about breast-related body image stress. According to the data from the BEQ, the patients were not very comfortable with their breasts while naked, and felt that the size of their breasts was important. This shows how important the appearance of their breasts is to the patients and how important the need for good communication about their breast-related body image issues is. In order for the patients to be comfortable communicating with their physicians, the physicians need to be open, honest, and direct. To reinforce this point, the patients felt that the advice they could give medical students is to be direct and honest.
The physicians believe that they are comfortable speaking with their patients about breast-related body image issues. However, the majority of the physicians do not initiate the conversation. There is a disconnect between what the patient prefers, and what the physicians are doing. This is important to know so that the patients can receive the care that they need to get through their diagnosis and treatment of breast cancer.
There were a couple of limitations to this study. First, the patients were newly diagnosed and had early stage breast cancer. This excluded patients with metastatic breast cancer and patients with a previous breast cancer diagnosis. This study included a small sample size which is necessary for a pilot qualitative study. In the future a larger, more focused, study will determine the exact way that patients prefer their physicians communicate about breast-related body image issues in order to improve quality for the patient (Cohen et al).
Acknowledgments
Supported, IN PART, by grant 1UL1RR031973 from the Clinical and Translational Science Award (CTSI) Program of the National Center for Research Resources, National Institutes of Health.
Supported, IN PART, by the Wisconsin Medical Society Foundation Summer Fellowship in Government and Community Service.
Supported, IN PART, by the Medical College of Wisconsin Department Research Fund- Breast Cancer
Medical College of Wisconsin Department of Surgery
Breast Cancer Patients at the Froedtert and the Medical College of Wisconsin Clinical Cancer Center
Breast Care Staff at the Froedtert and the Medical College of Wisconsin Clinical Cancer Center
Funding: Supported, IN PART, by grant 1UL1RR031973 from the Clinical and Translational Science Award (CTSI) Program of the National Center for Research Resources, National Institutes of Health.
Supported, IN PART, by the Wisconsin Medical Society Foundation Summer Fellowship in Government and Community Service.
Supported, IN PART, by the Medical College of Wisconsin Department Research Fund- Breast Cancer
Footnotes
Mallory Cohen received her BS from the University of Illinois at Urbana Champaign and became a student at the Medical College of Wisconsin in 2009. She will graduate with an MD in May 2013.
Rebecca Cogwell Anderson, Ph.D. is currently Professor and Director of Psychological Services: Division of Transplant surgery, Medical College of Wisconsin, Milwaukee, WI. Dr. Anderson is the author of 2 books, 8 book chapters, and over 75 journal articles. She is currently involved in outcomes research with breast cancer patients.
Kathleen Jensik received her MSW from Loyola University and came to the Medical College of Wisconsin in 2006. Kathleen served as a social worker at Lynn Sage Breast Cancer Program, a Program Director/Counselor at Stillwaters Cancer Support Services, and is currently a Program Coordinator at the Medical College of Wisconsin. Kathleen oversees a large Breast Cancer Research Program and coordinates a Psychosocial Study for Cancer Patients.
Qun Xiang received her MS in statistics from Iowa state university and came to the Medical College of Wisconsin in 2005. Qun served as statistician at the Quantitative Health Service in the Department of Pediatrics. Qun joined the Biostatistics Consulting Service in Jan of 2007.
Jessica Pruszynski received her Ph.D. in statistics from Baylor University in Waco, Texas, and came to the Medical College of Wisconsin in 2010. Jessica serves as an assistant professor in the Division of Biostatistics.
Alonzo Walker received his MD from the University of Florida College of Medicine after completing a residency in General Surgery. He came to the Medical College of Wisconsin in 1983. Alonzo served as the Medical Director at the Froedtert and Medical College of Wisconsin Breast Care Center. Dr Walker served as Chief of the Division of General Surgery, and was the Program Director in General Surgery. Alonzo is currently the Ruth Teske Professor in Surgical Oncology and the Senior Associate Dean for Faculty Affairs and Diversity at the Medical College of Wisconsin.
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Contributor Information
Mallory Cohen, Email: mcohen@mcw.edu, Institution: Medical College of Wisconsin, Address: 2510 N 124th St. Apt #146, Wauwatosa, WI 53226, Telephone: 847-989-3774.
Rebecca C. Anderson, Email: rsanders@mcw.edu, Institution: Medical College of Wisconsin, Address: 9200 W Wisconsin Ave., Milwaukee, WI 53226, Telephone: 414-955-6932.
Kathleen Jensik, Email: kjensik@mcw.edu, Institution: Medical College of Wisconsin, Address: 9200 W Wisconsin Ave., Milwaukee, WI 53226, Telephone: 414-805-9001, Fax: 414-454-0152.
Qun Xiang, Email: qxiang@mcw.edu, Institution: Medical College of Wisconsin, Address: 8701 Watertown plank Road, Milwaukee, WI 53226, Telephone: 414-955-8391, Fax: 414-955-6513.
Jessica Pruszynski, Email: jpruszynski@mcw.edu, Institution: Medical College of Wisconsin, Address: 8701 Watertown plank Road, Milwaukee, WI 53226, Telephone: 414-955-8358, Fax: 414-955-6513.
Alonzo P. Walker, Email: awalker@mcw.edu, Institution: Medical College of Wisconsin, Address: 9200 W Wisconsin Ave., Milwaukee, WI 53226, Telephone: 414-805-5737, Fax: 414-805-5771.
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