1. Background
Breast Cancer (BC) is one of the most common types of cancer in women (1, 2). The incidence of BC in women was 22 per 100 000. However, in the last few decades, we have seen an increase in the survival rate in patients with BC. The survival rate of women with BC from the first decade of the 21st century has increased from 75% (2000-2002) to 77.2% (2012 - 2014) (3). More survival rate after the diagnosis of BC has already highlighted the role of psychological factors in improving quality of life (QOL) in patients (4).
On one hand, the research background shows that cancer treatment (Surgery, Radiotherapy, and Systematic Treatment Selection) can be associated with physical and psychological consequences (3, 5-8). Physical changes such as hair loss and sexual problems and psychological changes such as the loss of QOL, body image dissatisfaction, and difficulty in emotion regulation in Breast cancer survivors (BCS) after surgery are common in such patients (4).
Among the cancer treatments, surgery can lead to anxiety, depression, body disfiguration, poor QOL, and sexual dysfunction (3). Surgery can also be associated with some consequences such as pain and psychological problems in admitting the new body (9). One of the types of therapeutic interventions in cancer is mastectomy. Mastectomy has negative effects on body image, sexual function, and QOL in patients (10). BCS experience disappointment due to the body disfiguration after surgery. Research findings show that, even after 18 months of the treatment of cancer, despite improvement in physical function, the indices of emotion regulation and QOL in patients with cancer did not significantly improve (4).
On the other hand, body image is a psychological structure that reflects the person's perceptions, emotions, and attitudes about his or her body and can affect sexual function and satisfaction (11). The body image has two positive and negative dimensions. Positive body image is not defined solely by the absence of a negative body image and is somehow the appreciation of the person towards his/her body, although it may include some aspects the person considers unpleasant (12). Negative body image is one of the most common concerns in women with BC (13).
In the BCS, the body image may be affected by various factors, including socioeconomic status, treatment method, QOL, and sexual function (3). The research background shows that the patient's perception of body image after surgery has a significant difference compared to before surgery (1).
Sexual function is one of the factors that have a close interaction with body image. Generally, a positive body image is associated with sexual function and satisfaction (9, 11). The female sexual dysfunction (FSD) in women with BC is highly prevalent (14). Mastectomy, in particular, can damage body image and, subsequently, reduce sexual function. The results of the study by Darwish et al. (15) showed that body image scores and sexual function in women under modified radical mastectomy (MRM) are significantly lower. In addition to the damage to the body image and sexual function, the QOL decreases in women with BC. Studies have shown that coping behaviors in patients with BC can affect their QOL (16). In this regard, maladaptive emotion regulation strategy has been identified as a trans-diagnostic mechanism underlying the psychiatric syndrome in patients with BC (17).
Today, we see the growth of scholarly research focusing on body image, sexual function, and QOL in women after the oncological treatment of BC (3). Studies have shown that the negative effects of surgery in patients with BC, especially on body image and sexual function, remain unchanged over time (4).
2. Objectives
Knowing the important factors in the body image, QOL, sexual function, and emotion regulation can facilitate the process of improving BCS. Despite the increasing growth of studies about physical and psychological components, the interaction of these indices has not been studied yet. Therefore, the present study was conducted to investigate the predictive role of body image and sexual function in QOL after MRM, considering the mediating role of emotion regulation.
3. Methods
The present study was a cross sectional study in the form of correlational design based on path analysis. Data were collected from March to December 2016. A total of 90 patients (18 - 65 years old, Median = 44.12, standard deviation = 7.34) under the MRM in the early stages of BC (stage IA to IIB), 6 months after completing an oncology treatment using respondent-driven sampling (RDS) method (18), that is a combination of chain sampling and a mathematical model (Markov chain theory and networks bias), were considered for the study. The sample size (n = 90) was estimated based on the allocation of 5 subjects per each parameter (19). Data were collected, using questionnaires and interviews. The instruments included a demographic checklist, structured clinical interviews, Multidimensional Body-Self Relations Questionnaire (MBSRQ), Female Sexual Function Index (FSFI), The WHO Quality of Life assessment short version (WHOQOL-BREF), and the Difficulties in Emotion Regulation Scale (DERS). Also, data of each patient were collected from archives in the pathology department.
The inclusion criteria included: 1) age range of 18 to 65 years; 2) history of BC; stage 1 or 2; 3) passing minimum 1 and maximum 5 years from mastectomy; and 4) obtaining informed consent for participation in the study. The exclusion criteria included: 1) history of chronic diseases such as cardiovascular, kidney, liver, diabetes, asthma, thyroid disease, rheumatoid arthritis (RA), cerebrovascular disease, and connective tissue disease; 2) taking the drug (Opioid Analgesics, Anti-nausea, and steroids) 3 months before the study.
The demographical checklist was developed by the researcher to collect personal information such as age, marital status, and history of the disease (20).
Structured clinical interview (SCID) is a clinical interview used to diagnose the dysfunctions of axis 1 based on DSM-5 (21). The kappa coefficient for all of the current diagnoses and life expectancy diagnosis was 0.52 and 0.55, respectively (22).
The sexual function of participants was evaluated through the Persian-language version of P-FSFI with 19 items. Higher scores show more sexual function. Scores are in the range of 2 to 36. The validity and reliability of this scale have been reported as desirable in Iranian society (23).
In this study, Cronbach's alpha was 0.88.
MBSRQ with 46 items was designed by Cash. It was designed to measure a person's perception from his/her body image and assess the body image on a 5-point Likert scale (1 = totally opposite to 5 = fully agree). The validity and reliability of this tool have been reported as desirable in previous studies (24).
The Quality of Life Scale QOLS was evaluated by WHOQOL-BREF that is a 26-item questionnaire. The range of item scores is from 1 to 5; the highest score indicates the better QOL (25).
DERS with 36 items was designed by Gratz and Roemer to evaluate emotion regulation patterns. This tool is designed in the form of a 5-point Likert scale. The validity and reliability of this tool have been reported as desirable in previous studies (26).
3.1. Statistical Analysis
The data were analyzed, using Pearson's correlation coefficient, linear regression analysis, stepwise regression, and Path Analysis in Amos and Statistical Package for the Social Sciences (SPSS) software Version 22 (SPSS, Inc., Chicago, IL, USA). The assumptions of the parametric tests were examined before the selection of the statistical test. The results of the Kolmogorov–Smirnov (K-S) test showed that the distribution of the scores of the participants in the research in all variables was normal (P > 0.05). The assumption of the linearity of the relationship between the variables was also examined by the analysis of variance and the presupposition was confirmed (P < 0.01).
3.2. Ethical Approval
All stages of the study were carried out after obtaining informed consent from the participants and based on the Declaration of Helsinki (DoH). The ethics committee of Cancer Research Center, Shahid Beheshti University of Medical Sciences, approved this study.
4. Results
Sixty-one cases had right breast cancer and the most affected area in both breasts was the upper quartile (57.12%); 73% of the patients had a tumor size in the range of 1 to 6 cm, and the average tumor size was 5.11 ± 2.74 cm. In 54.39% of the cases, 1 - 5 lymph nodes were found in the affected side axilla. Sixty percent of the tumors (54 patients) were from invasive ductal carcinoma. Two patients had medullary breast carcinoma (MBC), 2 had Invasive lobular breast cancer, 1 had Ductal carcinoma in situ (DCIS), and 1 had sarcoma. In Table 1, the Pearson correlation test results are presented.
As shown in Table 1, there was a direct relationship between body image, sexual function, and QOL in patients undergoing mastectomy. Also, there was a reverse relationship between the difficulty in emotion regulation and body image, sexual function, and QOL (P < 0.01).
To investigate the mediating role of difficulty in emotion regulation in the relationship between body image, sexual function, and QOL, path analysis was used to differentiate the criterion variables.
Table 2 shows that in the prediction of QOL based on the body image, difficulty in emotion regulation had a mediating role. Body image was also a predictor of QOL and difficulty in emotion regulation.
| Variable | b Coefficient | Standard Error | Beta | t | |
|---|---|---|---|---|---|
| Predictor: body image | Constant value | 9.712 | 0.311 | - | 19.076a |
| Criterion: QOL | body image | 0.691 | 0.049 | 0.702 | 14.390a |
| Predictor: body image | Constant value | 39.521 | 2.503 | - | 21.311a |
| Criterion: difficulty in emotion regulation | body image | -3.648 | 0.413 | -0.829 | -11.708a |
| Predictor: difficulty in emotion regulation/body image | Constant value | 11.581 | 0.811 | - | 15.072a |
| Criterion: QOL | body image | 0.739 | 0.211 | 0.784 | 8.279a |
| difficulty in emotion regulation | -0.689 | 0.041 | -0.382 | -4.713a |
The Results of Regression Analysis to Predict QOL Based on Body Image with the Mediating Role of Difficulty in Emotion Regulation
As shown in Table 3, the difficulty in emotion regulation had a mediating role in predicting the QOL based on sexual function. Difficulty in emotion regulation was also a predictor of the QOL.
| Variable | b Coefficient | Standard Error | Beta | t | |
|---|---|---|---|---|---|
| Predictor: sexual function | Constant value | 15.129 | 0.539 | - | 30.720a |
| Criterion: QOL | self-esteem | 0.921 | 0.089 | 0.811 | 15.322a |
| Predictor: sexual function | Constant value | 36.290 | 1.369 | - | 19.321a |
| Criterion: difficulty in emotion regulation | self-esteem | -2.512 | 0.329 | -0.813 | -15.295a |
| Predictor: difficulty in emotion regulation/sexual function | Constant value | 20.092 | 0.711 | - | 26.720a |
| Criterion: QOL | sexual function | 0.229 | 0.019 | 0.627 | 8.213a |
| self-esteem | 0.574 | 0.093 | 0.421 | 6.715a |
The Results of Regression Analysis to Predict QOL Based on Sexual Function with the Mediating Role of Difficulty in Emotional Regulation
Table 4 shows that the body image and sexual function are predictors of QOL.
| Path | Direct Effect | Indirect Effect |
|---|---|---|
| Body image → difficulty in emotion regulation → QOL | 0.811 | 0.572 |
| Sexual function → difficulty in emotion regulation → QOL | 0.791 | 0.403 |
Direct and Indirect Effects of Body Image and Sexual Function on QOL with the Mediating Role of Difficulty in Emotion Regulation
5. Discussion
This study was conducted to investigate the predictive role of body image and sexual function in QOL after MRM, considering the mediating role of emotion regulation. The results of this study showed a direct relationship between body image and sexual function with QOL, as well as an inverse relationship between body image and the difficulty in emotion regulation. Also, body image, sexual function, and difficulty in emotion regulation are predictors of QOL.
Although the present study is the first of its kind, extensive research literature supports the distinct relationship between the studied variables in this study.
The results of this study showed a significant relationship between body image, sexual function, and QOL in mastectomy patients. Consistent with our results, the results of a study by Soon et al. (10) showed that mastectomy had negative effects on body image, sexual function, and QOL of patients. In this regard, the results of a study carried out by Thomas et al. (11) showed that body image and perceptions of the person from his/her body affect sexual function. Also, Holmberg et al. (9) showed that a positive body image is associated with good sexual function and satisfaction. Besides, Darwish et al. (15) concluded that the scores of body image and sexual function in women under MRM are significantly low and related. In addition, Kowalczyk et al. (3) emphasized that body disfiguration, the loss of QOL, and sexual dysfunction can be considered a consequence of the surgery in the treatment of cancer. In this regard, Hsiao et al. (4) believe that despite improvement in physical functions, the QOL index in patients with cancer, even after 18 months of treatment, did not show a significant improvement.
The findings of the present study showed that the difficulty in emotion regulation has a mediating role in predicting QOL based on sexual function and body image. In line with our results, the results of Guimond et al.’s study (17) showed that maladaptive emotion regulation strategy is considered a trans-diagnostic mechanism underlying in patients with BC. Also, Lai et al. (16) showed that coping behaviors of patients with BC have a significant effect on their QOL. The results of a research conducted by Hsiao et al. (4) showed that after 1.5 years of treatment, and despite the improvement of physical functions, the emotion regulation indices did not show significant improvement. Darwish et al. (15) showed that Egyptian BCS reported lower overall global QOL. Also, Munshi et al. (27) concluded that patients with breast conservation surgery (BCS) had better sexual enjoyment and future perspective scores compared with mastectomy patients.
Mastectomy women, due to impairment in body image, endure stress and tension in the long period because mastectomy causes the patient to remember having cancer. Therefore, they often use adaptive mechanisms focusing on the emotion (emotion focus coping). The continuous use of these matching mechanisms can lead to high levels of anxiety that can damage sexual aspects and ultimately the QOL.
The implementation of this study had some limitations. The most important limitation of the present study was the lack of follow-up of patients in the form of a coherent study, which is suggested to be investigated in future studies. Also, a clinical trial to examine the effectiveness of emotional therapeutic interventions could be a good route for future studies.
5.1. Conclusions
The results of this study showed that sexual attractiveness dependent on body image, proper sexual function, and QOL in patients with BC under mastectomy can be affected by the difficulty in emotion regulation. The design of emotional therapeutic interventions to reduce the difficulty of emotion regulation can lead to improved QOL in patients.
