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. Author manuscript; available in PMC: 2019 Jun 1.
Published in final edited form as: J Health Psychol. 2017 Jan 30;24(7):909–917. doi: 10.1177/1359105317690035

Body image satisfaction among male military veterans with cancer

Greer A Raggio 1,2, Aanand D Naik 3,4, Jennifer Moye 1,2
PMCID: PMC5658257  NIHMSID: NIHMS881130  PMID: 28810396

Abstract

Impaired body satisfaction is commonly reported among cancer patients. This study prospectively evaluated body image disturbance among male military veterans with head and neck or colorectal cancer. Patients (N = 109) completed measures at three points post-diagnosis. Results showed about one-third of participants reporting body-related concerns. Endorsement did not change significantly during the study period. Predictors of worse body satisfaction included younger age, lower education, less social support, and weight loss. Results indicate a substantial minority of men with cancer endorsing body image disturbance, and highlight psychosocial circumstances and weight change as key considerations.

Keywords: body satisfaction, cancer, male veterans, psychosocial, weight loss

Introduction

Body dissatisfaction is prevalent among individuals with histories of cancer, with rates ranging widely from 11 to 86 percent across published studies (Benedict et al., 2016; Carpentier and Fortenberry, 2010; DeFrank et al., 2007; Rhondali et al., 2013). Cancer treatments may alter one’s physical appearance through scarring, changes in body composition, or surgical removal of affected body parts. Poor body image among cancer patients has been linked to a variety of negative outcomes including depression, anxiety, and sexual dysfunction (Rhondali et al., 2013; Sharpe et al., 2011), and it is rated by most patients as a concern requiring targeted support (Soothill et al., 2001).

Weight change and body image concerns in cancer

A number of predictive factors have been associated with body image disturbance in the context of cancer. These include younger age (e.g. Fingeret et al., 2010), certain cancer treatments (e.g. chemotherapy for breast cancer; Biglia et al., 2010; Carelle et al., 2002; Fingeret et al., 2014), lack of emotional/social support (e.g. Fobair et al., 2006), and worse overall health status (e.g. Benedict et al., 2016). Few studies have examined the impact of weight change on body satisfaction during or following cancer treatment. Some data identify substantial weight loss as a predictor of poorer body image and worse overall survival. This is often in the context of progressive cancer, where a decline in body weight may accompany broad physical deterioration (Rhondali et al., 2013). Additionally, weight loss may result from physical limitations imposed by surgery or other invasive treatments; for example, patients with head and neck cancer (HNC) frequently suffer from both substantial weight losses (up to 10% of baseline body weight) and poor body satisfaction, considering the high visibility of facial disfigurement and limitations on swallowing in this population (Capuano et al., 2008; Fingeret et al., 2012). In contrast, some studies, particularly within the breast cancer literature, have found significant associations between weight gain and body dissatisfaction (e.g. Helms et al., 2008; Raggio et al., 2014). It is also possible that weight change (in either direction) poses a direct threat to body image, independent of the aforementioned clinical factors. These inconsistencies and lingering questions necessitate further exploration of the impact of weight change on body satisfaction in the context of cancer.

Gender differences in body image concerns

Notably, the existing data on body image in cancer largely reflect the experience of women, particularly those with breast cancer. While some findings do suggest comparable rates of body image disturbance between men and women with similar cancer diagnoses (e.g. Fingeret et al., 2010), the established predictors of poor body image among women (e.g. younger age) have not consistently been found in male-only cancer samples (e.g. Harrington et al., 2009). Furthermore, the limited research conducted among men has focused on prostate and testicular cancer (e.g. Carpentier and Fortenberry, 2010; Harrington et al., 2009; Smith et al., 2002; Taylor-Ford et al., 2013); this is problematic, given that other cancer subtypes such as melanoma cancer and HNC (e.g. DeFrank et al., 2007) produce more visible disfigurement, potentially placing these individuals at higher risk for body dissatisfaction. Indeed, Fingeret et al. (2010) found that 36 percent of respondents with oral cancer endorsed moderate or severe distress regarding their appearance although no differences in prevalence between men and women were shown. Together, these data call for more research on body dissatisfaction among men across a greater range of cancer diagnoses.

Study aims

This study attempted to build on the limited literature on body image among men with cancer, and extend the scope of these data by focusing on weight change as a prospective predictor of body image in the months following cancer diagnosis. Participants (N = 109) were male military veterans with diagnoses of either HNC or colorectal cancer (CRC). These cancer subtypes were selected due to their high prevalence among military veterans (Moye et al., 2010) and commonalities in long-term side effects (e.g. nutritional compromise secondary to difficulty eating, nausea, decreased appetite, constipation, and diarrhea). The primary study aims were as follows: (1) to quantify and describe body image concerns reported by male military veterans with either HNC or CRC and (2) to examine potential predictors of body image at the 18-month follow-up visit, with a focus on weight change. Based on theory and the available literature, it was hypothesized that patients with more advanced cancer stage and/or greater weight loss during treatment would report poorer body image at 18 months.

Methods

Participants and recruitment

Participants (N = 109) were recruited from tumor registries and patient databases from large VA medical centers in New England and the Southwestern United States for a longitudinal cohort study. To be eligible for study participation, veterans were required to be English speaking. Those with psychotic or dementing disorders, and patients at or approaching end-of-life (i.e. hospice care), were excluded. Individuals with incident diagnoses of either HNC (n = 41) or CRC (n = 68) were included in study analyses although data were also collected from veterans with esophageal and gastric cancers; these individuals were ultimately excluded from statistical analyses due to small sub-group size. Similarly, two female veterans from the initial study sample were excluded from the present analyses. Sample size was determined on the basis of power analyses (these methods are described elsewhere; Naik, et al., 2013).

Procedure

Participants were identified at diagnosis and completed in-person, comprehensive biopsychosocial assessments at 6, 12, and 18 months after cancer diagnosis. Most interviews occurred at either local VA medical centers or in veterans’ homes. To reduce measurement bias, trained interviewers read each question aloud and recorded participant’s responses. For items with a Likert scale response format, participants were provided with a paper copy of the scale for reference. The study was approved by the Institutional Review Board and Research and Development Committee of each participating institution.

Measures

Demographic variables

Participants reported their age, sex, racial/ethnic identity, level of education, and marital status.

Clinical variables

Information about participants’ cancer diagnoses, including cancer tumor site and stage, was obtained from the medical record. Participants’ self-reported cancer treatments (i.e. surgery, chemotherapy, and/or radiation) were also confirmed by medical record review.

Body mass index and weight change

Body mass index (BMI) values were extracted from the medical record at the time of diagnosis, and 6 months and 18 months post-diagnosis, to examine changes in height-adjusted weight values during the study period.

Emotional support

One item from the Medical Outcomes Study Social Support Index (Hays et al., 1995) was used to measure emotional support: “How often do you have someone you can count on to listen to you when you need to talk?” The item was rated 1–4, with higher scores indicating more social support (0 = None of the time, 1 =A little of the time, 2 = Some of the time, 3 = Most of the time, and 4 =All of the time).

Body image

Three items from the European Organization for Research and Treatment of Cancer (EORTC) CRC module (Sprangers et al., 1999) were used to measure body image: (1) “Have you felt physically less attractive as a result of your disease or treatment?” (2) “Have you been feeling less feminine/masculine as a result of your disease or treatment?” (3) “Have you been dissatisfied with your body?” Items were rated 1–4 with higher scores indicating greater symptom endorsement in the prior week (1 = Not at all, 2 =A little, 3 = Quite a bit, and 4 = Very much). These three items from the EORTC CRC module were asked to all patients in this study. The EORTC quality of life questionnaire is commonly used to assess health-related quality of life in cancer patients participating in international clinical trials and has demonstrated very good psychometric characteristics.

In addition to considering responses at the item level, summary scores for body image at each time period were calculated as a sum of the three items. Inter-item reliability was very good at all assessment points (Time 1, α = .88; Time 2, α = .84; and Time 3, α = .79).

Statistical analyses

The prevalence of body image disturbance was determined using descriptive analyses consisting of frequency and mean scores. Associations with body image at the bivariate level were determined using: Pearson correlation coefficients for continuous variables (age, emotional support, and change in BMI); Student’s t test for two-level categorical variables (education, race, cancer type, and cancer treatment); and analysis of variance (ANOVA) analyses for multi-level categorical variables (e.g. cancer stage). Changes over time were evaluated with repeated-measure ANOVA and paired t tests. Multivariate prediction (with body image score as the dependent variable) was examined using multiple linear regressions, entering only variables that were significant in bivariate analyses. Prior to the analyses, subscale scores were centered to standardized variables for statistical purposes. All analyses were performed using SPSS 22.0.

Results

Demographics and clinical data

All participants (N = 109) were males, and ranged in age from 50 to 88 years (M = 65.68, standard deviation (SD) = 8.57). Most participants reported having a partner (65.1%) and high social support (M = 3.25, SD = 1.10) at baseline. The majority was Caucasian (80.7%), and about half had a high school education or less (44.0%).

Participants had diagnoses of HNC or CRC (37.6% vs 62.4%, respectively). Disease stage, as defined by the American Joint Committee on Cancer (AJCC; Edge and Compton, 2010), was evenly spread: Stage I (28.4%), II (28.4%), III (22.9%), and IV (20.3%). Regarding cancer treatment, 80.7 percent underwent surgical procedures, 54.1 percent received chemotherapy, and 37.6 percent received radiation (treatments were not mutually exclusive).

BMI at the time of diagnosis ranged from 17 to 55 kg/m2 (M= 28.47, SD=6.29). At follow-up assessments, BMI ranged from 18 to 44 kg/m2 (M= 26.30, SD=4.97) 6 months after diagnosis, and from 15 to 45 kg/m2 (M= 26.07, SD=4.71) at 18 months. Change in BMI from the time of diagnosis to 18 months post-diagnosis ranged from a loss of 22.0 kg/m2 to a gain of 6.1 kg/m2. Overall, there was a trend toward weight loss in this clinical population (BMI change, M= −2.39, SD = 4.85); this distribution was negatively skewed (skew = −1.37), with a substantial minority of participants demonstrating considerable decline in body mass (9.2% of the sample had a loss of >10 kg/m2). Differences between diagnosis and 18-month BMI measurements were statistically significant in the full sample (t[108]=5.15, p< .001).

Body image

In general, about one-third of the sample reported a negative impact of cancer on body image (Table 1). At Time 1 (6 months), the most frequent complaint was feeling dissatisfied with one’s body, with 33.9 percent endorsing this item “A little,” “Quite a bit,” or “Very much.” Additionally, 27.5 percent endorsed “Feeling less physically attractive,” and 28.4 percent reported “Feeling less masculine” as a result of cancer or cancer treatment. Summed scores (combining the three items) were similar at Time 2 (12 months) and Time 3 (18 months), and did not change significantly between diagnosis and 18 months (Time 1, M= 4.45, SD=2.28; Time 3, M= 4.49, SD=2.20; t[109]=− 0.18, p= .86).

Table 1.

Prevalence of body image disturbance among men with HNC or CRC at 6-, 12-, and 18-month post-diagnosis.

During the past week Not at all (%) A little (%) Quite a bit (%) Very much (%) Mean SD
Time 1 (6 months)
Felt physically less attractive 72.5 17.4 3.7 6.4 1.44 0.84
Feeling less masculine 71.6 14.7 8.3 5.5 1.48 0.87
Been dissatisfied with body 66.1 16.5 15.6 1.8 1.53 0.82
Total – – – – 4.45 2.28
Time 2 (12 months)
Felt physically less attractive 70.6 19.3 8.3 1.8 1.41 0.72
Feeling less masculine 69.7 16.5 9.2 4.6 1.49 0.85
Been dissatisfied with body 61.5 28.4 8.3 1.8 1.50 0.73
Total – – – – 4.40 2.00
Time 3 (18 months)
Felt physically less attractive 72.5 13.8 4.6 9.2 1.50 0.95
Feeling less masculine 73.4 13.8 10.1 2.8 1.42 0.79
Been dissatisfied with body 65.1 18.3 11.9 4.6 1.56 0.88
Total – – – – 4.49 2.20
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HNC: head and neck cancer; CRC: colorectal cancer; SD: standard deviation.

Predictors of body image at 18-month post-diagnosis

In bivariate analyses, younger age, lower perceived emotional support, lower education, and weight loss were associated with worse body image ratings at Time 3 (Table 2). These variables were also significantly associated with body image in multiple linear regression analyses (Table 3). Cancer type, stage, and treatments were not significantly associated with body image.

Table 2.

Baseline characteristics (N = 109) predicting body image at 18-month post-diagnosis.

Mean SD Body image
Statistics p
Age (range: 50–88) 65.68 8.57 r =−.27 .02
Emotional support (range: 0–4) 3.22 1.13 r =−.29 .003
Change in BMI (range: −22.00 to 6.05) −2.39 4.86 r =−.26 .007
n %
Partner Has a partner 71 65.1 t =−0.69 .49
Does not have a partner 38 34.9
Education High school or less 48 44.0 t =−2.20 .03
College (some or graduate) 61 66.0
Race African American and other 21 19.3 t =0.53 .60
Caucasian 88 80.7
Cancer type Head and neck 41 37.6 t =1.18 .24
Colorectal 68 62.4
Cancer stage Stage I 31 28.4 F =0.97 .41
Stage II 31 28.4
Stage III 25 22.9
Stage IV 22 20.3
Treatment type Surgery 88 80.7 t =0.42 .68
Chemotherapy 59 54.1 t =−0.38 .71
Radiation 41 37.6 t =−1.36 .18
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BMI: body mass index; SD: standard deviation.

Body image measured at Time 3 (18 months after cancer diagnosis); higher body image scores indicate worse body image.

Table 3.

Predictors of body image disturbance at 18-month post-diagnosis.

B Standard error β t p
Constant 1.94 0.71 2.74 .01
Age −0.02 0.01 −0.19 −2.10 .04
Social support −0.23 0.08 −0.26 −2.92 .00
Education 0.37 0.17 0.19 2.11 .04
BMI change −0.24 0.08 −0.25 −2.84 .01
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BMI: body mass index.

F(4, 99)=7.59; p <.001; R2= .24.

Discussion

This study attempted to extend the dearth of research on body image among male patients with cancer using a sample of male military veterans with HNC or CRC. Given the historical focus on women in the body image literature, this study sought to quantify the experience of male cancer patients at various points following diagnosis. Furthermore, this article examined change in body mass, in addition to more established demographic and clinical features, as a predictor of body image over the 18-month assessment period.

Results show that a significant minority of veterans reported disruptions in one or more aspects of body image following diagnosis. At the 18-month visit, 35 percent reported some dissatisfaction with their bodies, 28 percent felt physically unattractive at least some of the time, and 27 percent felt insufficiently masculine. These findings align with the published literature, which shows rates of body image disruption and dissatisfaction ranging from 15 to 37 percent of among men with testicular or prostate cancer (e.g. Arai et al., 1997; Harrington et al., 2009; Rudberg et al., 2002). Interestingly, scores on each item, in addition to summed body image scores, did not change significantly during treatment. One possible explanation for this finding relates to study methodology, specifically that most participants had already undergone surgery by the first study assessment. Indeed, the breast and gynecological cancer literature show a rise in body image disruption immediately following surgery, and these concerns remain amplified for up to 2 years thereafter (e.g. Dahl et al., 2010; Fobair et al., 2006).

Significant predictors of body image in this sample included age, education, and emotional support, where veterans who were younger and had less education, and those who reported lower perceived emotional support at diagnosis demonstrated worse body image scores at the 18-month follow-up visit. These findings largely mirror the existing literature (Fingeret et al., 2014; Holly et al., 2003; Iredale et al., 2006), indicating that advancing age, greater education, and more social support may buffer cancer survivors from negative body image after cancer treatment. Interestingly, disease variables—including cancer stage, diagnosis (HNC vs CRC), and treatment type—were not significantly associated with body satisfaction at any time point. It may be that, in cancers with overlapping clinical outcomes, such as the two digestive cancers examined in this study, clinical characteristics are relatively less important factors in the experience of body image compared to demographic characteristics, despite the fact that radiation and surgery therapies result in modest to significant physical changes.

As expected, decreases in height-adjusted body weight (BMI units) significantly predicted poorer body image scores 18 months following diagnosis. While high BMI has been identified as a predictor of poorer body satisfaction in prior studies of patients with HNC (e.g. Fingeret et al., 2014), this article is the first, to the authors’ knowledge, to demonstrate this link in CRC. In cancer survivors, different cancer treatments may be associated with disparate weight change tendencies; a large, longitudinal sample of multiple cancer types would permit analysis of the effect of weight change in the context of initial BMI class, considering important variables such as cancer treatment, cancer type, gender, social class, etc.

This study has multiple strengths. First, participants were followed prospectively over the course of 18 months following cancer diagnosis; this contrasts the largely cross-sectional data in the existing literature. Second, changes in height-adjusted weight (BMI) were extracted from the electronic medical record for all patients, providing an accurate measure of longitudinal weight change as opposed to self-reported weight fluctuations. Finally, this study adds to the limited literature on body image disturbance in cancer by surveying military veterans with cancers of the colon/rectum and head/neck. Further research should attend to cancer diagnoses among men, apart from prostate cancer, considering the comparable or higher rates of visible disfigurement in non-genital cancers.

This study is limited by the small, three-item representation of the construct of body image, which may not have captured all relevant aspects of body image disruption. Additional research should include a greater variety of questions surveying aspects of perceived attractiveness and perceived disapproval from others (e.g. patients’ spouses). In addition, the external validity of this study is limited by the specificity of the participant sample (i.e. male military veterans recruited from VA Healthcare System). Although veteran status is common (approximately, 50% over age 65 are veterans; Federal Interagency Forum on Aging-Related Statistics, 2012), the extent to which the veterans differ from non-veterans is unknown. Veterans are at an elevated risk for combat-related posttraumatic stress disorder (PTSD), which might conceivably increase risk of other forms of psychological distress. Conversely, veterans who receive care within the Veterans Health Administration (VHA) experience integrated health care, including free nutrition and weight management programs, which may collectively serve as a protective factor. In addition, the absence of women in the study sample disallowed potentially important sex-based interaction analyses; for instance, future studies may evaluate whether weight loss impacts body image differently between men and women. Finally, the absence of baseline (pre-diagnosis) data precludes comparisons of participants’ typical body image to post-cancer scores; retrospective bias may have led participants to erroneously attribute pre-existing concerns about their physical appearance to the cancer experience.

Still, this study presents a novel, previously unreported profile of military veterans experiencing cancer-related body image disturbance. The data reveal that approximately one-third of men experience body image disturbance after a diagnosis of CRC and HNC, and that those who are younger, less educated, and have lower social support may be at particular risk. The data also serve as a reminder of the universal impact of cancer treatment, which appears to present in a similar fashion among men and women. Furthermore, body image disturbances appear to persist long after cancer diagnosis; thus, any such distress detected during clinical contact, or as assessed using validated measures (as in this study), should be taken seriously. Patients must be informed of the potential for body image disturbance soon after or at diagnosis, and early intervention in the form of counseling referral and psychoeducation should be provided. Cancer survivorship generally, and shifts in self-esteem and perceived attractiveness more specifically, deserve greater research attention in the published literature.

Acknowledgments

The authors thank the members of the Veterans Cancer Rehabilitation Study (Vetcares) Research team. The authors are also indebted to the veterans who have participated in their research studies and allow them to contribute to their health care. This article has not been published elsewhere and has not been submitted simultaneously for publication elsewhere.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was provided by the Department of Veterans Affairs Rehabilitation Research and Development Service (#CIN 13-413). This work was supported with resources from and the use of facilities at the Boston VA Medical Center and the Houston Center for Innovations in Quality, Effectiveness and Safety at the Michael E. DeBakey VA Medical Center.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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