Table 2.

Review of body image articles

Author (Year)	Population/Sample Size	Primary objective	Type of Study/Instruments Used	Findings
Clarke, S. A.; Newell, R.; Thompson, A.; Harcourt, D.; Lindenmeyer, A. (2014)22	• 20 participants • Various head and neck cancers • United Kingdom • Primarily British Caucasian • Post-treatment • Participants identified with altered body image	• Investigate the relationship between psychological and demographic variable and appearance-related adjustment post-neck cancer (NC) in those who identified themselves as having a visible difference in appearance	Design: • Mixed-methods cross-sectional survey Instruments Used: • DAS-241 • HADS2 • FNE3 • Dispositional optimism • Social support • Qualitative accounts of appearance-related adjustment Other measures: • Age range and gender, marital status, ethnic group, HNC-type, treatment, prosthesis, primary area of appearance concern	Incidence: • Females had poorer appearance-related adjustment compared to males. • No significant correlations between age or head and neck cancer (HNC) type, anxiety, depression, or distress/dysfunction. • No significant difference between baseline and follow-up data for distress/dysfunction. • Lower distress/dysfunction was significantly correlated with lower anxiety, depression, psychological distress, more optimism, and more social support. Consequences: • Participants utilized coping strategies for body image alterations that included hiding disfigurement, focusing on positive aspect, and giving less importance to appearance.
Dropkin (1999)26	• 117 participants • Various head and neck cancers • United States • Primarily males and Caucasian • Pre- and post-treatment	• Describe body image reintegration as it related to quality of life in the surgical head and neck cancer patient population	Design: • Cohort study Instruments Used: • Ways of Coping Questionnaire • The State Trait Anxiety Inventory • Disfigurement/Dysfunction Scale • Coping Behaviors Score Other measures: • Anxiety and anticipation of disfigurative surgery	Risk factors: • Body image reintegration (coping effectiveness) was significantly lower when disfigurative surgery was anticipated. • Body image reintegration was significantly lower if participant had previous radiation or chemotherapy treatment. • Trait anxiety (prior to surgery) scores were lower than state anxiety (post-surgery) scores.
Fingeret, M. C.; Vidrine, D. J.; Reece, G. P.; Gillenwater, A. M.; Gritz, E. R. (2010)21	• 75 participants • Oral cavity cancer • United States • Primarily Caucasian • Pre-treatment	• Provide novel data about multiple dimensions of body image through existing measures	Design: • Multidimensional analysis Instruments Used: • BIS4 • ASI-R5 • BSS6 • FNAES7 • HNS8 • BSI-189 • Structured clinical interview	Incidence: • 77% of participants identified current and/or future appearance-related concerns. • Less than 5% of patients concerned with their appearance had difficulty coping and experienced distress with daily functioning. • Gender differences were not found for any of the body image measures. Risk factors: • Age was inversely correlated with body image concerns. • Patients with T1 tumors had higher body image concerns compared with those with T2–T4 tumors. • Depression was the strongest and most consistent predictor of body image outcomes across the measures.
Fingeret MC, Yuan Y, Urbauer D, Weston J, Nipomnick S, Weber R. (2012)2	• 280 participants • Oral cavity cancer, cutaneous cancer, and head and neck cancers • United States • Primarily males and Caucasian • Pre- and post-treatment	• Obtain descriptive information about the presence of body image concerns, satisfaction with care received about body image issues, and interest in psychosocial intervention for head and neck cancer patients undergoing surgical treatment	Design: • Cross-sectional study Instruments Used: • BIS4 • FACT-HN10 • Body Image Survey	Incidence: • 75% of participants reported feeling concerned/embarrassed at some point following diagnosis. • 38% of participants currently or previously avoided social activities due to appearance, speech, or eating concerns. • 33% of participants endorsed behavioral difficulties involving reassurance seeking, increasing grooming or checking behaviors, or avoidance of grooming. • Levels of body image dissatisfaction increased after initial surgical operation and remained significantly elevated following surgery compared to preoperative levels. Risk factors: • Younger patients were associated with having significantly higher levels of body image dissatisfaction.
Fingeret MC, Hutcheson KA, Jensen K, Yuan Y, Urbauer D, Lewin JS (2013)20	• 280 participants • Oral cavity cancer, cutaneous cancer, and head and neck cancers • United States • Primarily males and Caucasian	• To evaluate associations among speech, eating, and body image concerns for patients undergoing surgical treatment for head and neck cancer	Design: • Cross-sectional study Instruments Used: • BIS4 • A survey designed for the study • FACT-G21,22	Incidence: • 75% of participants reported feeling concerned/embarrassed at some point following diagnosis. • 23.6% of participants reported body image concerns exclusively to physical appearance with the top concern involving scarring/disfigurement. • Patients within the speech and eating concerns group had higher levels of body image/appearance dissatisfaction than those with appearance-only based concerns. Consequences: • Patients with speech and eating concerns were more likely to avoid social activities and have interest in psychosocial interventions to address appearance difficulties. • Participants with any type of body-related concern (speech, eating, or physical appearance) had worse quality-of-life outcomes related to physical, functional, social, and emotional well-being.
Flexen, J.; Ghazali, N.; Lowe, D.; Rogers, S. N. (2011)1	• 204 participants • Various head and neck cancers • United Kingdom • Primarily males • Post-treatment	• Assess concerns about appearance based on what the patients would like to discuss during their consultation	Design: • Descriptive cross-sectional study Instruments Used: • UW-QOL11 • PCI12	Incidence: • 14% of clinics had patients that considered body image as a serious problem or wanted to discuss it at their consultation. Risk factors: • Younger participants and those with more advanced tumors reported the most concerns with appearance.
Henry, M.; Ho, A.; Lambert, S. D.; Carnevale, F. A.; Greenfield, B.; MacDonald, C.; Mlynarek, A.; Zeitouni, A.; Rosberger, Z.; Hier, M.; Black, M.; Kost, K.; Frenkiel, S. (2014)18	• 14 participants • Various head and neck cancers • United States • Participants identified with disfigurement from the illness/treatment • Post-treatment	• To explore the lived experience of disfigurement during head and neck cancer (HNC) by considering its impact and its physical, psychological, existential/spiritual, and social influences	Design: • Qualitative study Instruments Used: • Interviews	Risk factors: • Support and acceptance of family and friends post-treatment can determine patients’ adaptation to disfigurement. Consequences: • Disfigurement caused feelings of low self-esteem, unattractiveness, embarrassment, and inadequacy. • Men had distress with dysfunction rather than disfigurement. • Participants believed disfigurement attracted attention and reactions in social settings, further increasing their anxiety and self-consciousness.
Huang, S.; Liu, H. E. (2008)25	• 44 participants • Oral cancer • Taiwan • Primarily male participants • Post-treatment	• To identify the body image of oral cancer patients and to compare the changes in the body image of oral cancer patients after receiving a cosmetic rehabilitation program	Design: • Quasi-experimental study Instruments Used: • MBSRQ-AS	Incidence: • Participants had significantly higher satisfaction with their appearance following the rehabilitation program than during the baseline assessment.
Katre, C.; Johnson, I. A.; Humphris, G. M.; Lowe, D.; Rogers, S. N. (2008)23	• 252 participants • Oral and oro-pharyngeal cancer • United Kingdom • Primarily males • Post-treatment	• To describe appearance issues in patients following surgery for oral and oropharyngeal squamous cell carcinoma	Design: • Descriptive cross-sectional study Instruments Used: • DAS241 • UWQOL v414	Incidence: • 35% of participants reported no change in appearance. • 40% reported minor change in appearance. • 19% were bothered by appearance but remained active. • 5% limited their activities due to feeling significantly disfigured. • 40% reported self-consciousness with some aspect of their appearance. Risk factors: • Adjuvant radiotherapy and tumor stage were correlated with appearance concerns. Consequences: • Participants were most concerned about saliva, swallowing, speech, chewing, and appearance.
Liu, H. E. (2008)24	• 97 participants • Various head and neck cancers • Taiwan • Post-treatment	• To assess the changed satisfaction with appearance of the participants between pre-surgery and at study time	Design: • Retrospective cross-sectional study Instruments Used: • BIVAS and BAS subscale of the Chinese version of MBSRQ13,16,17	Incidence: • 16% of participants maintained the same level of satisfaction with their appearance compared with pre-treatment level. • 10.7% of participants reported improved satisfaction with appearance compared with pre-treatment level. • Females reported more dissatisfaction with appearance than males. Risk factors: • Radiotherapy treatment or not, age, duration from last radiotherapy, and number of treatment modalities were significantly associated for satisfaction with appearance.
Millsopp (2005)19	• 278 participants • Oral and oro-pharyngeal cancer • United Kingdom • Pre- and post-treatment	• To identify which patients in the series reported that appearance was an issue	Design: • Retrospective review Instruments Used: • UQWOL11 Other measures: • Age, gender, cancer site, tumor size, tumor stage, radiotherapy, operation, resection or dissection, and American Society of Anesthesiologists (ASA) (physical status prior to surgery)	Incidence: • Appearance scores did not differ between men and women or between those under or over 65 years old. • 114 participants reported a low appearance score, rated appearance as important, or mentioned appearance in their questionnaire. Risk factor: • Tumors over 2 cm, T staging in advance of stage 1, flap surgery, segmental resection, and a neck dissection were most likely seen in the patients with appearance concerns.
Rhoten, B. A.; Deng, J.; Dietrich, M. S.; Murphy, B.; Ridner, S. H. (2014)4	• 43 participants • Various head and neck cancers • United States • Primarily male and Caucasian • Pre- and post-treatment	• To examine the relationship between body image and depressive symptoms in patients who have been treated for head and neck cancer (HNC)	Design: • Cross-sectional study Instruments Used: • BIQLI17 • CES-D18	Incidence: • Participants with baseline depressive symptoms had increases in levels of depression at the end of treatment and 6 weeks post-treatment, with a return to baseline by 12 weeks post-treatment. • Body image scores were statistically significantly higher at 12 weeks post-treatment than at the immediate end of treatment and at 6 weeks post-treatment. Risk factor: • Body image was inversely related to levels of depressive symptoms.
Teo, I.; Fronczyk, K. M.; Guindani, M.; Vannucci, M.; Ulfers, S. S.; Hanasono, M. M.; Fingeret, M. C. (2016)3	• 140 participants • Various head and neck cancers • United States • Primarily male and Caucasians • Pre-treatment	• To evaluate body image issues and concerns among patients as they prepare to undergo reconstructive surgery as part of cancer treatment	Design: • Cross-sectional study Instruments Used: • BIS4 • BIDQ19 • ASWAP20 • ASI-R5 • BICSI21 • FACT-HN10 • Head and Neck Survey	Incidence: • 20% of participants scores varied in their level of appearance distress. • 7% of participants scores varied in their level of functional difficulties. • No significant differences in body image scores between female and male participants. Consequences: • Participants reported appearance distress about physical and sexual attractiveness, satisfaction with appearance, changes in self-esteem, behavioral avoidance, and social functioning. • Participants reported functional difficulties with eating and speech abilities.

¹Derriford Appearance Scale, ²Hospital Anxiety and Depression Scale, ³Fear of Negative Evaluation, ⁴Body Image Scale, ⁵Appearance Schemas Inventory Revised, ⁶Body Satisfaction Scale, ⁷Fear of Negative Appearance Scale, ⁸Head and Neck Survey-Appearance Subscale, ⁹Brief Symptom Inventory, ¹⁰Functional Assessment of Cancer Therapy Scale-Head and Neck Version, ¹¹University of Washington Quality of Life Questionnaire, ¹²Patient Concerns Inventory, ¹³Multidimensional Body-Self Relations Questionnaire Appearance Scale, ¹⁴University of Washington Quality of Life Scale version 4, ¹⁵Body image Visual Analogue Scale, ¹⁶Body Area Satisfaction, ¹⁷Body Image Quality of Life Inventory, ¹⁸Center for Epidemiological Studies Depression Scale, ¹⁹Body Image Disturbance Questionnaire, ²⁰Adapted Satisfaction with Appearance Scale, ²¹Body Image Coping Strategies Inventory, ²²Functional Assessment of Cancer Therapy-General (FACT-G)