1. Background
Breast cancer represents a multifaceted condition that precipitates significant physical and psychological changes in affected women (1). The disease engenders various social and psychological challenges, primarily due to its physical repercussions, among which psychological distress stands out as a critical factor impacting patients' quality of life (2). Following a breast cancer diagnosis, women may undergo one of two surgical interventions: Breast-conserving surgery, which involves the removal of the tumor and a margin of surrounding healthy tissue, or mastectomy, entailing the complete removal of the breast. These procedures can lead to body image disturbances, profoundly affecting patients' mental well-being (3).
For women with breast cancer, the experience of physical alterations leads to a shift in the perception of physical attractiveness. Consequently, they may no longer view themselves as sexually or physically appealing, a change directly attributed to their altered self-image (4). Many women diagnosed with breast cancer experience psychological distress, which progressively diminishes their well-being. Psychological well-being is characterized by positive emotions and a comprehensive sense of life satisfaction across various domains, including family, personal, and social work (5).
Despite the adverse impact of cancer, research has highlighted that confronting the illness can lead to positive transformations post-diagnosis and treatment, a phenomenon known as post-traumatic growth (PTG) (6). Post-traumatic growth encompasses significant changes across multiple dimensions of life, such as a deeper understanding of life, enhanced personal strength, enriched social relationships, a heightened interest in spirituality, recognition of personal resilience, and improved capacity for emotional expression and optimism about the future (7). Historically, the emphasis has been on recognizing and addressing the negative repercussions of cancer among survivors. Nonetheless, the constructive outcomes of post-traumatic growth, spurred by the cancer experience, its consequences, and its treatments, significantly enhance life and health quality. Consequently, exploring the relationship between psychological well-being and post-traumatic growth in women with breast cancer is of paramount importance.
2. Objectives
The present study aims to address the following questions: (1) Is there an association between body image and psychological well-being and post-traumatic growth among women with breast cancer who have undergone mastectomy surgery? (2) Which aspects of body image and mental well-being are predictive of post-traumatic growth in women with breast cancer and a history of mastectomy surgery?
3. Methods
3.1. Study Design and Participants
The study conducted is descriptive and correlational in nature. Data collection was carried out through both library and field methods. The library method involved reviewing background information from articles, books, and credible scientific websites. In the field method, after obtaining an introduction letter from the university and visiting medical centers (hospitals, clinics), the purpose of the research was explained to potential participants, and confidentiality of the information was assured, leading to informed and voluntary participation. Data collection was conducted by the researcher between the years 2021 and 2022. The statistical population comprised all women with breast cancer who sought treatment at specialized centers (Dey Specialized Hospital, Jihad University Breast Clinic of Tehran, Iranian Breast Surgeons Association) and had undergone mastectomy surgery. The initial sample size was 350 individuals. After applying the inclusion criteria (being married, having undergone mastectomy surgery, and having no history of mental illness), the final sample consisted of 276 participants who were analyzed. Participants who were willing to join the study were selected based on availability, and their responses to the questionnaires were analyzed. The inclusion criteria for the sample were: (1) Undergoing mastectomy surgery; (2) being married; (3) absence of a history of experiencing or being diagnosed with a chronic and severe mental illness or disorder at the time of conducting the research or in the recent past (The General Health Questionnaire [GHQ] and a self-report form were utilized to assess the mental health status of participants).
3.2. Ethical Statement
The study received approval from the Ethics Committee of Islamic Azad University, Central Tehran Branch, Tehran, Iran (approval code: IR.IAU.CTB.REC.1401.141). All participants were asked to read an informed consent document and complete the questionnaires anonymously. They were also informed of their right to withdraw from the survey at any point.
3.3. Measures
3.3.1. Body Image Questionnaire by McKinley and Hyde (1996)
To assess body image, the study utilized the Body Image Questionnaire developed by McKinley and Hyde (8) in 1996. This questionnaire comprises 2 dimensions: Body Control and Body Shame. Responses are recorded on a five-point Likert Scale, ranging from “completely agree" to “completely disagree". The validity of the questionnaire's main sections has been verified by its creators. Its validity is further supported by its correlation with variables such as appearance orientation, body esteem, restricted eating, and other appearance control behaviors. The internal consistency of the Body Control and Body Shame subscales, along with appearance control beliefs, has been reported with Cronbach's alpha values of 0.89, 0.75, and 0.72, respectively (8). The validity of this questionnaire was also confirmed in a study by Norozi et al., where Cronbach's alpha was employed to ascertain reliability. In their research, Cronbach's alpha values for the dimensions of body image, specifically body surveillance and body shame, were 0.83 and 0.90, respectively (9).
3.3.2. Ryff Psychological Well-Being Questionnaire (RSPWB-18)
The Psychological Well-Being Scale, developed by Ryff in 1989, initially comprised 120 items. Subsequent revisions introduced shorter versions with 84, 54, and 18 items. According to Ryff's model, psychological well-being encompasses 6 dimensions: Self-acceptance (maintaining a positive self-view), positive relationships with others (forming warm, intimate connections and the ability to empathize), autonomy (experiencing independence and resisting social pressures), purpose in life (having goals and finding meaning in life), personal growth (sensing continuous development), and environmental mastery (the capacity to manage one's surroundings) (10). In this study, psychological well-being is measured using the scores obtained from the abbreviated 18-item scale developed by Ryff and Keyes in 1995. The overall internal consistency of the test, as determined by the Cronbach's alpha method, is reported to be approximately 0.55 (11). Zanjani Tabasi assessed the reliability of this questionnaire using the internal consistency method, resulting in Cronbach's alpha coefficients for the subscales ranging between 0.62 and 0.90 (12).
3.3.3. Posttraumatic Growth Questionnaire Tedeschi & Calhoun (PTGI)
This self-report tool, designed by Tedeschi and Calhoun in 1996, consists of 21 items aimed at measuring post-traumatic growth. Respondents are asked to rate their experiences on a six-point Likert scale ranging from 0 ("I did not experience any change") to 5 ("I experienced a lot of change"). The questionnaire is organized into five subscales: (1) Relationships with others, (2) new possibilities, (3) personal strength, (4) spiritual changes, and (5) appreciation of life. In the study conducted by Tedeschi and Calhoun, the overall Cronbach's alpha coefficient of the questionnaire was reported as 0.90, with the subscales' reliability ranging from 0.67 to 0.85. Their findings indicated that individuals who had undergone psychological trauma scored higher on average (SD = 20.47, M = 69.75) compared to those without such experiences (13). In a separate study by Seyed Mahmoudi et al., the questionnaire's overall alpha coefficient was found to be 0.92, demonstrating optimal reliability through the test-retest method (r = 0.94) (14).
3.4. Statistical Analysis
Statistical indicators and methods, such as mean, standard deviation, correlation coefficients, and regression analyses, were utilized to analyze the data. Furthermore, the significance level for this study was set at α = 0.05, and data analysis was conducted using SPSS software, version 27.
4. Results
To address the first research question regarding the correlation between body image and psychological well-being with post-traumatic growth among women with breast cancer and a history of mastectomy, it was found that there is a significant positive relationship between psychological well-being and post-traumatic growth in women who have undergone mastectomy surgery for breast cancer (P < 0.01). Multiple regression analysis was employed to answer the second research question. The findings from the multiple regression analysis on the influence of body image dimensions on post-traumatic growth indicate that only one percent of the variance in post-traumatic growth can be predicted by the linear combination of Body Control and Body Shame (Table 1).
Table 1.Regression Analyses Predicting Post-traumatic Growth from Body Image in Women with Breast Cancer with A History of Mastectomy Surgery
| Variables | Sum of Squares | df | Mean Square | F | P | R | R2 |
|---|---|---|---|---|---|---|---|
| Post-traumatic growth | 1158.96 | 2 | 579.48 | 1.64 | 0.195 | 0.109 | 0.005 |
| 96320.80 | 273 | 352.82 | |||||
| 97479.76 | 275 | ||||||
| Post-traumatic growth | 31464.64 | 6 | 5244.10 | 21.36 | 0.001 | 0.568 | 0.308 |
| 66015.12 | 269 | 245.40 | |||||
| 76.97479 | 275 |
As illustrated in Table 1, the observed F value (F(2,273) = 1.64) does not indicate a significant effect on post-traumatic growth; hence, it can be inferred that the dimensions of body image are not predictors of post-traumatic growth in women with breast cancer who have undergone mastectomy surgery. The details of the analysis are provided in Table 2. According to Table 2, the Beta coefficient for Body Control is 0.080, which is not significant (t = 0.127). Similarly, the Beta coefficient for Body Shame is -0.127, which is also not significant (t = 1.800). Therefore, there is no significant association between Body Control and Body Shame with post-traumatic growth in this group of women. Furthermore, the results from the multiple regression analysis on the impact of psychological well-being dimensions on post-traumatic growth revealed that 32% of the variance in post-traumatic growth can be predicted by a linear combination of self-acceptance, positive relationships with others, autonomy, environmental mastery, purpose in life, and personal growth (Table 2). The observed F value in Table 1 (F = 21.36) signifies a substantial effect on post-traumatic growth; thus, it can be concluded that psychological well-being components, in general, are predictors of post-traumatic growth in women with breast cancer and a history of mastectomy surgery. The regression analysis details in Table 2 show that dimensions of self-acceptance (β = 0.112), autonomy (β = 0.31), and purpose in life (β = 0.316), with consideration of the t statistic and a 95% confidence level, can predict changes related to post-traumatic growth. In other words, increases in self-acceptance, autonomy, and purpose in life are associated with enhanced post-traumatic growth in these women.
Table 2.Influence Coefficients of Body Image and Subjective Well-Being on Post-traumatic Growth
| Criterion and Predictor Variables | b | SEM | Beta | t | P-Value |
|---|---|---|---|---|---|
| Post-traumatic growth | |||||
| Body control | 0.311 | 0.276 | 0.080 | 1.127 | 0.261 |
| Body shame | 0.424 | 0.236 | 0.127 | 1.800 | 0.073 |
| Post-traumatic growth a | |||||
| 1 | 0.949- | 0.462 | 0.112 | 2.054 | 0.041 |
| 2 | -0.655 | 0.347 | 0.099 | 1.887 | 0.060 |
| 3 | 2.115 | 0.399 | 0.310 | 5.303 | 0.001 |
| 4 | -0.128 | 0.451 | 0.022 | 0.404 | 0.686 |
| 5 | -1.824 | 0.336 | 0.316 | 5.433 | 0.001 |
| 6 | -0.622 | 0.464 | 0.075 | 1.340 | 0.181 |
a1, self-acceptance; 2, positive relationships; 3, autonomy; 4, mastery of the environment; 5, purposeful life; 6, personal growth.
5. Discussion
The findings of this study indicate that there is no significant association between body image and its components, including body shame and Body Control, with post-traumatic growth. These results align with the findings of Izydorczyk et al. (15) and diverge from those of Kiarasi et al. (16). To interpret these findings, it can be suggested that a link between post-traumatic growth and body image might emerge when individuals exhibit high resilience. In other words, if resilience and other positive psychological factors act as mediators between body image and post-traumatic growth, the relationships between the research variables could become significant (17). Conversely, the lack of significant associations in this study could be attributed to various factors. Notably, protective psychological factors such as resilience were not considered, and the study was conducted shortly after the participants underwent mastectomy surgery, possibly preventing them from achieving relative adaptation. Additional influencing factors might include environmental support, particularly from spouses, quality of life, and the participants' level of welfare and well-being, each of which has been highlighted in previous research.
Changes in body image are positively associated with depressive symptoms. Concerns about body image may lead to increased psychological distress in women following mastectomy. However, factors such as the passage of time and individual protective factors, including resilience, may influence these outcomes. While some women may adapt to the psychological distress and report higher levels of post-traumatic growth, others may experience intensified dissatisfaction with their bodies due to the surgery, exacerbating depression symptoms and leading to decreased adaptation and, consequently, lower levels of post-traumatic growth.
Furthermore, the study findings reveal a positive association between psychological well-being and its components (such as autonomy or independence, purpose in life, and self-acceptance) and post-traumatic growth. Research by Salehi and Desheiri (18) found that post-traumatic growth is positively and significantly related to variables of psychological well-being, mental spirituality, and hope. Additionally, the variables of psychological well-being and existential well-being, along with the component of hopeful outlooks, play a significant role in predicting post-traumatic growth.
Holtmaat et al. (19) demonstrated that post-traumatic growth is predicted by psychological well-being and personal meaning. Components of well-being, such as interpersonal relationships and having goals and hope, imbue an individual's life with meaning. The belief in having a unique role or purpose is tied to taking responsibility for one's life. The ability to fully realize personal potential contributes to a sense of peace, satisfaction, and transcendence, facilitating the integration of life's adversities and challenges. Individuals with high psychological well-being are likely to maintain positive relationships with others, have a positive self-view, possess a sense of purpose, and exhibit resilience against difficulties. Since these attributes are integral to post-traumatic growth, psychological well-being can predict post-traumatic growth. Other commonalities between psychological well-being and post-traumatic growth include self-confidence and high self-esteem, which encourage engagement in innovative and challenging endeavors. People with high psychological well-being are often well-regarded by their family, friends, and peers, leading them to embrace challenging activities. As a result, following any adversity or trauma, they are poised for growth and excellence through the acquisition of new experiences, knowledge, and relationships.
Given that this study was conducted shortly after mastectomy surgery, future research is recommended to consider the time elapsed and overall adjustment. The proximity of the study to the treatment process could influence the research outcomes and findings.
