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. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: Health Care Women Int. 2019 Jun 25;41(4):397–411. doi: 10.1080/07399332.2019.1615916

Psychometric Development of a New Body Image Scale for Breast Cancer Survivors

Erika Biederman a, Andrea Cohee a, Patrick Monahan b, Timothy Stump b, Victoria Champion a
PMCID: PMC6930352  NIHMSID: NIHMS1529336  PMID: 31237491

Abstract

The purpose of this study was to psychometrically test a body image scale for breast cancer survivors (BCS). Data (n=1127 BCSs) were obtained via telephone and mailed questionnaires. Psychometric testing was conducted using Cronbach’s alpha, item-total correlations, factor analysis, linear regression, and Pearson's correlations. Data demonstrated a unidimensional seven-item scale with Cronbach's alpha=0.88 and item-total correlations ranging from 0.367 to 0.829. Construct validity was demonstrated with 45% of the body image variance explained by constructs in the conceptual model [F(14,784) = 48.35, p<0.000]. The body image scale demonstrated high internal consistency reliability, unidimensionality, and construct validity.

Keywords: breast cancer, survivorship, quality of life

Approximately 85–90% of women diagnosed with breast cancer in most high-income countries can expect to survive longer than five years through earlier diagnosis and better treatment options (Allemani et al., 2018). The sequelae from cancer and its treatment demand attention since these women can anticipate living long, disease-free lives. A commonly reported issue among survivors, including survivors who underwent mastectomies, lumpectomies, breast reconstruction, chemotherapy, and/or radiation, is body image alteration after breast cancer. The defining attributes of body image include perceptions, thoughts, and feelings related to a change in appearance (Fingeret, Nipomnick, Crosby, & Reece, 2013). Following breast cancer diagnosis and treatment, survivor body image issues include feeling less attractive, disliking how clothes fit, and feeling self-conscious (Collins et al., 2011; Hopwood, Fletcher, Lee, & Al Ghazal, 2001). With changes in their breasts and perceived femininity, breast cancer survivors may experience difficulty relating sexually with a partner and may be prone to resulting psychological issues such as depression and anxiety (Collins et al., 2011; Lasry et al., 1987; Ussher, Perz, & Gilbert, 2012).

While body image alteration is a well-documented problem throughout the US (Collins et al., 2011), Canada (Baxter et al., 2006; Lasry et al., 1987), UK (Hopwood et al., 2001), Australia (Przezdziecki et al., 2013), and Europe (Falk Dahl, Reinertsen, Nesvold, Fosså, & Dahl, 2010; Moreira & Canavarro, 2010), few psychometrically tested scales to assess body image in oncology patients and survivors have been developed (Baxter et al., 2006; Collins et al., 2011; Hopwood et al., 2001; Lasry et al., 1987). First, a 7-item body image index was tested in patients with mastectomies and lumpectomies but not in patients who had undergone chemotherapy in hospitals in Montreal, Canada (Lasry et al., 1987). This index showed a relationship between body image, depression, and fear of recurrence and had a Cronbach’s alpha of 0.81 (Lasry et al., 1987). Next, the body image scale (BIS), a 10-item scale that demonstrated high reliability (Cronbach’s alpha 0.93), was developed in the UK (Hopwood et al., 2001). The BIS scale, however, was adapted generally for oncology patients and not specifically for breast cancer survivors who may have unique body image issues related to sexuality. Third, the Body Image after Breast Cancer Questionnaire (BIBCQ), tested on Canadian patients, showed reliabilities between 0.77–0.87 among six scales (Baxter et al., 2006). The BIBCQ consisted of 53 questions, which may limit its usefulness in clinical settings and impose response burden on participants. Finally, an 8-item body image scale, developed among US breast cancer survivors, showed a relationship between body image, depression, and anxiety with a Cronbach’s alpha of 0.87–0.89 (Collins et al., 2011). This body image scale included patients who underwent mastectomies, chemotherapy, and radiation but did not include long term (three to eight years) breast cancer survivors.

Cancer related body image scales have been developed in Canada, the US, and the UK but several gaps limit their usefulness. First, most of these previously developed scales were not validated in samples of survivors more than two years post diagnosis (Collins et al., 2011; Hopwood et al., 2001; Lasry et al., 1987). Secondly, none of these prior scales described a conceptual framework to guide development, as body image has not been integrated into most quality of life conceptual frameworks assessing survivorship issues. Third, other body image scales have not holistically addressed the physical, psychological, and social dimensions of quality of life such as sexual functioning, fatigue, and relationship satisfaction.

The current scale was developed based on the conceptual definition of body image described above and tailored for long-term (three to eight years) breast cancer survivors, including those who underwent mastectomies, lumpectomies, radiation, and chemotherapy, and their specific issues. This new body image scale builds on previous work in Canada, the US, and UK by incorporating body image into both a quality of life framework with three domains (physical, psychological, and social) and a global measurement of well-being based on a breast reconstruction framework (Fingeret et al., 2013; Reaby, Hort, & Vandervord, 1994). Additionally, the current study was novel by including a sample of long-term breast cancer survivors who underwent mastectomies, lumpectomies, radiation, and chemotherapy. Varying treatments and length of time since diagnosis and treatment may produce differential effects on body image, making accurate assessments of body image useful to researchers and clinicians.

The purpose of the current analyses was to develop and psychometrically test a new body image scale, which could be used internationally across disciplines in clinical or research settings to measure breast cancer survivors’ body image during long-term survivorship. This body image scale was psychometrically tested for internal consistency reliability and construct validity. Knowledge of the impact that body image may have on physical, psychological, and social domains of quality of life could be important factors in patient and clinician decision making.

Research Hypotheses

Internal consistency reliability will be measured in the following ways:

  • The Cronbach alpha for body image will be 0.8 or above,

  • inter-item correlations will be less than 0.7,

  • and the corrected item-total correlations will exceed 0.4 for all items.

Construct validity will be demonstrated by the following:

  • Exploratory factor analysis will identify a unidimensional latent variable,

  • body image will be significantly associated with constructs in the physical, psychological, and social quality of life domains,

  • and proximal variables and body image will predict overall quality of life.

Conceptual Framework

The conceptual model (Figure 1) for this body image scale was modified from a breast reconstruction framework with the assumption that women undergoing breast reconstruction and breast cancer survivors have similar body image and quality of life issues (Fingeret et al., 2013). This body image scale is based on a biopsychosocial model, which posits physical, psychological, and social factors are related to quality of life. The conceptual model for this body image scale included antecedents, body image, proximal quality of life outcomes, and a distal quality of life outcome.

Figure 1.

Figure 1.

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Conceptual Model

Methods

Cross-sectional data were from a descriptive study in which women were surveyed by mail and telephone on a comprehensive set of demographic, physical, psychological, and social variables. Secondary data for this study were obtained as part of a larger quality of life study that compared breast cancer survivors and acquaintance controls (women who were not diagnosed with breast cancer) (Champion et al., 2014). Human subjects protection was obtained from the parent site institutional review (IRB) board of a large US Midwestern university and from each of the 97 cooperating sites within the US Eastern Cooperative Oncology Group (ECOG). Breast cancer survivors were recruited using the ECOG database as well as a large Midwestern cancer center. The women answered all applicable scales, including the body image scale.

Initially, a physician contacted eligible women and asked for permission to forward their names and contact information to the university. After consent was obtained, the university received the contact information and mailed the woman a brochure explaining the study followed by a phone call. A research assistant (RA) called the survivor and, if verbal consent was obtained, the woman was mailed the informed consent and questionnaire. Both the questionnaire and consent were returned in a postage-paid envelope. Follow-up reminder phone calls were made if the survey and informed consent were not received within two weeks. Of the survivors who agreed to participate, 84% returned data.

DeVellis recommends a two-step process for establishing content validity (DeVellis, 2016). First, the full content domain is identified through item generation, and then content experts review items (DeVellis, 2016). After items were initially developed, they were reviewed by two focus groups, composed of six to eight breast cancer survivors at least three years from treatment. The conceptual definition for body image was given to focus group participants. Then, researchers asked the focus group participants to judge items for relevance, clarity, and inclusiveness of breast cancer survivorship issues. After initial item content was confirmed, minor wording changes were suggested.

As a next step to establish content validity, content experts provided judgment of the items. Three senior quality of life researchers, one breast cancer survivor, and one PhD-prepared clinician were given the conceptual definition of body image and rated items based on relevance and clarity. Three items were deleted based on the content expert feedback. The item index of content validity (item-CVI) was used to determine the quantitative judgment of content validity. Item-CVI was found to be 1.00, with modified kappa statistic (k*) of 1.00.

Measures

Demographic measures, including current age and education, and treatment variables, such as type of surgery and chemotherapeutic regimen, were collected and confirmed through medical record audit. Other measures, including those in the physical, psychological, and social domains, were selected to reflect issues correlated with body image and related to overall well-being. Physical functioning and fatigue were measured for the physical domain. For the psychological domain, depression, anxiety, and fear of recurrence were measured. Marital satisfaction and sexual functioning were included for the social domain. The Index of Well-Being measured overall quality of life.

Physical Quality of Life Domains

The 10-item Physical Functioning Scale (PF-10) is part of the 36-item Short-Form Health Survey (SF-36) and measures physical activity limitations (Cronbach alpha=0.93) (McHorney, Ware Jr, Lu, & Sherbourne, 1994). The Functional Assessment of Cancer Therapy–Fatigue (FACT-F) is a subscale of the 33-item Functional Assessment of Cancer Therapy (FACT-G) scale. The FACT-F is a 13-item scale that measured fatigue. The FACT-F has demonstrated internal consistency (0.9), test-retest reliability (0.89), and convergent and discriminant validity among oncology patients (Yellen, Cella, Webster, Blendowski, & Kaplan, 1997).

Psychological Quality of Life Domains

The 20-item Center for Epidemiologic Studies–Depression (CES-D) Scale measured depression symptoms. The CES-D has demonstrated criterion-oriented and construct validity. Internal consistency alphas have ranged from 0.85–0.9 and test-retest reliabilities have ranged from 0.51–0.67 (Radloff, 1977). The State-Trait Anxiety Inventory (STAI) measured anxiety with two self-report scales measuring state and trait anxiety (Cronbach alpha = 0.97) (Spielberger, 2010). The State Anxiety Scale (STAI Form Y-1) includes 20 statements assessing current feelings or “state” (Spielberger, 2010). The Trait Anxiety Scale (STAI Form Y-2) includes 20 statements that assesses general feelings or “traits”. The Concerns About Recurrence Scale (CARS) measured fear of recurrence in breast cancer survivors with 34 items and demonstrated a Cronbach alpha of 0.97 (Vickberg, 2003). The CARS includes items assessing overall fear of recurrence and worries about death, health, role, and womanhood.

Social Quality of Life Domains

The 15-item ENRICH Marital Satisfaction Scale (ENRICH-MSS), measured marital satisfaction (Cronbach alpha of 0.86) (Fowers & Olson, 1993). The ENRICH measures areas of the marital relationship such as communication and sexual relationship. The 7-item Sexual Index Scale measured sexual functioning with a Cronbach alpha of 0.79. The Sexual Index Scale was modified from existing instruments and was composed of subscales for sexual difficulty and sexual enjoyment. The Northouse Spouse/Support measures the relationship between a spouse and breast cancer survivor regarding the breast cancer experience (Northouse, 1988). The Northouse Spouse/Support has demonstrated high internal consistency with reliability coefficients between 0.90-.094.

Distal Quality of Life Domain

The Index of Well-Being (IWB) is a 9-item scale often used to measure global well-being with a Cronbach alpha of 0.93. It has been used as a measure of quality of life in breast cancer survivors (Campbell, Converse, & Rodgers, 1976).

Sample

Data for the current study were part of a larger breast cancer survivor quality of life study that compared breast cancer survivors with acquaintance controls to identify differences in breast cancer diagnosis at a younger age versus those diagnosed at an older age. Only breast cancer survivor data were used, including younger and older survivors. Eligibility criteria included if the women were younger than forty-five years at diagnosis or ages fifty-five to seventy years at diagnosis; being three to eight years from initial treatment; Stage 1 through Stage 3 at original diagnosis; not having a recurrence of breast cancer; being treated with a chemotherapy regiment that included Adriamycin, Pacitaxel, and Cyclophosphamide to reduce variance related to treatment; and being able to read and write English.

Data Analyses

Reliability

Internal consistency reliability was measured with Cronbach alpha coefficients, inter-item correlations, and corrected item-total correlations. Cronbach alpha coefficients above 0.8, inter-item correlations below 0.7, and item-total correlations above 0.3 and below 0.7 were considered adequate.

Validity

Construct validity was measured through exploratory factor analysis and with correlations of body image to quality of life domains (physical, psychological, social). Exploratory factor analysis with the principal component analysis extraction method was conducted. Squared multiple correlations were specified as the initial estimates of communalities. Rotation was not used. Factor loadings above 0.4 were considered adequate. Pearson correlation coefficients of body image with selected measures (PF-10, FACT-F, CES-D, STAI, CARS, ENRICH-MSS, Sexual Index Scale, and Northouse Spouse/Support) of each quality of life domain (physical, psychological, and social) were first estimated to determine the relationships between body image and quality of life variables. A linear regression measured the impact of covariates, body image, and proximal quality of life variables on overall quality of life (as measured by the Index of Well-Being).

Results

The sample included 1127 breast cancer survivors who completed the survey. Table 1 describes the sample characteristics for this secondary analysis, and other demographics from the parent study have been described previously (Champion et al., 2014). The sample had a mean age of 57.1 and 14.5 years of education.

Table 1.

Demographic Characteristics (N=1127).

Characteristic X− SD
Age (years) 57.1 11.6
Education 14.5 2.7
Characteristic n %
Type of Surgery
 Mastectomy 590 52
 Lumpectomy 535 48
Education
 Less than High School 34 3
 High School or two year college 653 59
 Four Year college or more 423 38
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Abbreviations: X−=Mean, SD=Standard Deviation, n=number in sample

Reliability

Individual items of the body image scale were assessed for high inter-item correlations (above 0.7) that would indicate redundancy of items. One item had an inter-item correlation of 0.7 or greater with other items of similar content. The redundant item was, “I am satisfied with the appearance of my body.” Internal consistency reliability analysis was conducted with the redundant item deleted and a Cronbach alpha of 0.88 was obtained. Item-total correlations ranged from 0.367–0.829. The item-total correlations and means for the final 7-item scale are shown in Table 2.

Table 2.

Corrected Item-Total Correlation Coefficients.

Item Correlation X−
I feel attractive .727 3.48
I feel self-conscious during sexual activity because of the appearance of my body .367 3.17
I am satisfied with the way my clothes fit .708 3.15
Others find me attractive .588 3.50
I am satisfied with the appearance of my breasts .570 3.01
I am sexually attractive .705 3.09
I feel good about my body .829 3.14
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Validity

First, construct validity was tested by exploratory factor analysis resulting in factor loadings from 0.446–0.889, above the 0.4 threshold (see Table 3). The values of these loadings suggested a unidimensional latent body image variable. The Eigenvalue of the first factor was 4.602, while the remaining Eigenvalues suggested a leveling off in the scree plot at 0.942, 0.675, and 0.608. The first factor explained 93% of the variance shared between the seven items and 57.53% of the total observed variance.

Table 3.

Item Loadings for Exploratory Factor Analysis.

Item Factor Loading
I feel attractive .822
I feel self-conscious during sexual activity because of the appearance of my body .446
I am satisfied with the way my clothes fit .801
Others find me attractive .706
I am satisfied with the appearance of my breasts .661
I am sexually attractive .793
I feel good about my body .889
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Then, construct validity was tested by correlating each of the quality of life variables with body image and then regressing overall quality of life, as measured by the Index of Well-Being, with covariates, body image, physical functioning (PF-10 and FACT-F), psychological functioning (CES-D, STAI, and CARS) and social functioning (ENRICH-MSS, Sexual Index Scale, and Northouse Spouse/Support). Table 4 shows that body image was correlated with all of the quality of life variables. Additionally, body image was a predictor of overall quality of life even after adjusting for covariates and other quality of life variables. Based on the t and p values (see Table 5), the variables that were most strongly associated with well-being were physical functioning, body image, worry about recurrence, trait and state anxiety, depression, and spousal support. The combination of all variables in the model explained 48.35% of the variance in well-being.

Table 4.

Correlation of Quality of Life Variables with Body Image.

Variable R n
Physical Functioning (PF-10) .189** 1125
Functional Assessment of Cancer Therapy Fatigue Subscale (FACT-F) .362** 1123
Center for Epidemiologic Studies Depression Scale (CES-D) −.417** 1122
Concerns About Recurrence Survivor (CARS) −.351** 1151
State Anxiety Inventory (STAI) −.385** 1109
Trait Anxiety Inventory (STAI) −.465** 1106
Sexual Index Scale .303** 838
ENRICH Marital Satisfaction .261** 848
Northhouse Spouse/Partner .322** 847
Index of Well Being (IWB) .406** 1113
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Abbreviations: R=Pearson’s correlation, n=number in sample

p=<.001

Table 5.

Standardized Coefficients, t statistics, and p values for Index of Well-Being.

Variable Beta
coefficient		 t p
Current Age −.029 −.962 .336
Education .003 .115 .908
Type of Surgery .020 .761 .447
Body Image .087 2.775 .006
PF-10 .065 1.998 .046
FACT-F −.023 −.634 .526
CES-D −.084 −1.931 .054
CARS .084 2.776 .006
State Anxiety Inventory (STAI) −.123 −2.447 .015
Trait Anxiety Inventory (STAI) .352 −6.424 .000
Sexual Index .032 1.119 .264
ENRICH .052 1.574 .116
Northhouse Spouse/Partner .187 5.902 .000
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Discussion

The new body image scale demonstrated high internal consistency reliability and construct validity, and all hypotheses were supported. Of the original 8 items, inter-item correlations revealed one redundant item, “I am satisfied with the appearance of my body”. This item was correlated at 0.793 with the item “I am satisfied with the appearance of my breasts”. A Cronbach alpha of 0.854 was retained after removal of the item. The remaining items demonstrated good item-total correlations ranging from 0.367–0.829. The 7 items were used for subsequent analyses. Construct validity was tested using exploratory factor analyses and confirmation of theoretical relationships. Exploratory factor analyses supported a unidimensional factor with loadings of 0.446 or higher.

A significant problem with previously developed body image scales has been their focus on a time frame proximal to diagnosis and treatment. Our scale was developed for long-term survivors after initial accommodation to the disease and treatment has been made. Previous research has shown that as time since diagnosis increases, breast cancer survivors tend to have better quality of life (Dorval, Maunsell, Deschenes, Brisson, & Masse, 1998; Ganz et al., 2002). Some quality of life domain differences persist, however, between survivors and women who were never diagnosed with breast cancer (Dorval et al., 1998). Data from the current study were obtained from long-term survivors using a holistic approach to well-being including the physical, social, and psychological domains. Depression, anxiety, fatigue, fear of recurrence, sexuality, and body image remain concerns in long-term survivors (Champion et al., 2014).

A second problem with many prior body image scales is that they have not included survivors who received adjuvant chemotherapy as did the breast cancer survivors in the current study. Research has shown that receipt of chemotherapy and other systemic treatments (e.g., tamoxifen) can compromise quality of life further than those who do not receive those treatments (Ganz et al., 2002). Therefore, scales that have focused only on women who received surgical treatment for breast cancer may not reflect the body image issues of those who also received chemotherapy. Adjuvant chemotherapy can affect ovarian function, menses, and fertility (Letourneau et al., 2012; Morgan, Anderson, Gourley, Wallace, & Spears, 2012), which in turn can affect sexual function and quality of life (Gupta et al., 2006). Women who receive adjuvant chemotherapy may experience menopause and its associated symptoms of hot flashes, night sweats, and mood swings, which may exacerbate breast cancer survivor symptoms.

Support of theoretical relationships between the body image scale and symptoms frequently reported by breast cancer survivors will help inform future interventions. In the current study, body image was significantly and inversely associated with fatigue, depression, anxiety, and fear of recurrence. As body image improved, depression, anxiety, and fear of recurrence decreased. Other researchers have reported fatigue as a common physical problem reported in breast cancer (Bower et al., 2000; Tchen et al., 2003). Fatigue is often correlated with depression (Bower et al., 2000; So et al., 2009), and we found an inverse relationship (r=−.417, p≤.001) between depression and body image. Prior research has found that survivors have higher levels of depression and anxiety compared to age-matched controls (Champion et al., 2014). Additionally, both State and Trait anxiety were inversely correlated with body image, and other researchers have found an inverse relationship between anxiety and body image (Collins et al., 2011; Falk Dahl et al., 2010). Finally, fear of recurrence has been frequently cited as a major problem in breast cancer survivors (Costanzo et al., 2007; Härtl et al., 2003), a finding corroborated by our results.

In addition to individually experienced symptoms such as fatigue, depression, anxiety, and fear of recurrence, breast cancer survivors report problems in the social domain including marital satisfaction (Bower et al., 2000; Fobair et al., 2006), sexual functioning (Boquiren et al., 2016), and social support (Hughes et al., 2014). Body image was significantly correlated with marital satisfaction, sexual functioning, and social support indicating that these variables could be improved if body image was also improved. If, as this study found, body image is correlated with sexual functioning, interventions to target body image could be useful to improve sexual functioning in breast cancer survivors. Since overall marital satisfaction is often related to sexual functioning (Speer et al., 2005; Weihs, Enright, Howe, & Simmens, 1999), interventions that improve sexual functioning could also have a positive effect on the overall marital relationship.

As a final step, the authors regressed the Index of Well-Being on demographic variables, body image, and physical, psychological, and social domain variables. All proximal quality of life variables were significantly related to overall well-being when controlling for covariates Additionally, body image was a significant predictor even when all other variables were in the equation. The significant correlations of body image scores with quality of life variables suggest the potential benefits of developing interventions that target body image in breast cancer survivors.

As breast cancer survivors are now enjoying years of disease-free survival, persistent problems that accompany the diagnosis and treatment become prominent. Given that body image changes related to breast cancer have been documented across many high-income countries, this new body image scale could be used in interventions in the US as well as culturally adapted and translated for breast cancer survivors in other countries. Body image has an important role in increasing behaviors that lead to improved symptom management and quality of life in breast cancer survivors. The body image scale could be used as a screening tool during a primary care visit. If a survivor was indicating problems with body image, interventions on this construct could improve other symptoms, such as anxiety, depression, fatigue, or sexual/relationship dysfunctions.

Limitations

Limitations of this study must be acknowledged. The sample was obtained from the Eastern Cooperative oncology group, whose survivors are highly educated, have a high socioeconomic status, and are mostly Caucasian, which limits generalizability. Additionally, the data were cross-sectional so directionality of the relationship between body image and quality of life variables could not be determined.

Conclusions

The new body image scale demonstrated high internal consistency reliability, unidimensionality, and construct validity. At 7-items, this new body image scale is a short scale that could easily be administered in research and clinical settings as a potential marker for survivor issues with physical, psychological, social, and overall quality of life issues related to their cancer diagnosis and treatment. As breast cancer survivors are now enjoying years of disease-free survival, persistent problems that accompany the diagnosis and treatment become prominent. This new body image scale could be used in interventions to target body image in breast cancer survivors. Body image has an important role in increasing behaviors that lead to improved symptom management and quality of life in breast cancer survivors. The body image scale could be used as a screening tool during a primary care visit. If a survivor was indicating problems with body image, interventions on this construct could improve other symptoms, such as anxiety, depression, fatigue, or sexual/relationship dysfunction

Acknowledgments

This study was coordinated by the ECOG-ACRIN Cancer Research Group (Robert L. Comis, MD and Mitchell D. Schnall, MD, PhD, Group Co-Chairs) and supported in part by Public Health Service Grants CA189828, CA180795, CA37403, CA35199, CA17145 and CA49883, and from the National Cancer Institute, National Institutes of Health and the Department of Health and Human Services. Its content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute.

Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Numbers T32 CA117865 and K05CA175048 and the American Cancer Society Graduate Scholarship in Nursing Practice, GSCNP-17–120-01. Its content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, including the National Cancer Institute or the American Cancer Society.

Footnotes

Disclosures: The authors declare no potential conflicts of interest.

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