Breast cancer is so common that 1 in 17 women develops breast cancer in her lifetime (Health Promotion Board, 2009). The American Cancer Society (2010) estimated 1.4 million new diagnoses of breast cancer worldwide. In Singapore, breast cancer is the leading cancer among women with an annual incidence rate of 1300 (Singapore Cancer Society, 2008). Data from the National Registry of Diseases Office (2010) shows that breast cancer contributed to a significant 29.2% of cancer in Singapore women, most prevalent at the age group 55-59. The ethnic distribution of the disease is equal and the estimated lifetime risk of breast cancer is 5% which is much lower than that of the American and European women (Singapore Cancer Society, 2010). However, the incidence rate has been rising rapidly exceeding the rate in United States (Jara-Lazaro, Thilagaratnam, & Tan, 2010).
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Mastectomy is inevitable in patients with large breast tumors (Singapore Cancer Society, 2010). It has unique consequences because of the mutilation of an organ that represents a woman’s femininity and sexuality and plays an important role in sexual pleasure and stimulation. The paper reviews the literature relating to the psychosocial impact of mastectomy on a woman’s body image and sexuality which can affect her mental health. As survivorship of breast cancer following mastectomy becomes more common, the findings in this review are of significance to nurses caring for these women in providing interventions to address their psychological wellbeing.
2. Literature Review
The review has been divided into 3 stressors for post-mastectomy women: body image, sexual functioning and marital adjustment.
2.1 Body image
Ample studies had demonstrated mastectomy was associated with altered body image (Morris, 1979; Gottschalk, & Hoigaard-Martin, 1984; Lasry et al., 1987). A recent study conducted by Bakhta and Najafib (2010) also found that women who had undergone mastectomy had lower body image than healthy women. However, many other recent studies proved otherwise. Moreira and Canavarro (2010) conducted a longitudinal study on breast cancer patients and found only a slight increased in body shame during the period of surgery to 6-months after the treatment’s ending. Esmaili, Saiidi, Majd and Esmaieli (2010) conducted a survey on 90 women during the period of 1-3 months following mastectomy and found insignificant change in body image. Hopwood et al. (2000) found that 21% of the women reported no change in body image in the first 3 years following prophylactic mastectomy as they viewed the surgery as a good trade-off for better health.
The type of surgery has a predictive role on body image and various researchers have explored its impact on women’s adjustment. A quantitative research showed larger proportion of those who had mastectomy without immediate breast reconstruction reported problems with body image (Sackey, Sandelin, Frisell, Wickman, & Brandberg, 2010). Studies on the impact of type of surgery have revealed contradictory results with Hopwood et al. (2000) demonstrating that some women disliking the look or feel of the reconstructed breast.
Young women reported more body image problems (Bakhta, & Najafib, 2010) while older breast cancer patients showed greater acceptance of the mastectomy consequences (Ganz et al., 2002).
Salter (1997) states that patient’s acceptance of body changes is largely influenced by people’s reactions around her, implying that behaviour of the partners and nurses play the most important role in determining patients’ acceptance of their body regardless of the type of the surgery and the age of the patient.
2.2 Sexual functioning
Many researchers have demonstrated the strong impact of breast cancer and mastectomy on sexual function. Reported rates for post-mastectomy sexual problems range from a low 18.6% in those with mastectomy and reconstruction to a high 30.2% in those without reconstruction (Rubino, Figus, Lorettu, & Sechi, 2006). The main causes of post-mastectomy sexual problems were altered self-perceived sexual image (Yeo et al., 2004), loss of pleasurable sensation in the breasts and consequent decreased of sexual desire (Graziottin, 2007; Burwell, Case, Kaelin, & Avis, 2006). This shows that sexual difficulties can be attributed to physical problems.
2.3 Marital Adjustment
Mastectomy affects not only the patient but also her relationship with her partner. In the study of Avci, Okanli, Karabulutlu and Bilgili (2009), it was found that the patients had a moderate level of marital adjustment. Research has shown that quality of a woman’s relationship is a stronger predictor of sexual functioning than the alteration of the body after mastectomy (Alder et al., 2008; Zee et al., 2008).
Whilst each of these factors has been considered separately, it is important to acknowledge that they are interconnected. Women who have a poor body image following mastectomy have lower sexual satisfaction and are more dissatisfied with their relationship with their partners. Future research is needed to acknowledge this inter-relationship, in order to manage the multi-faceted consequences of mastectomy.
3.1 Relevance to nursing practice
This review has demonstrated that there is a compelling evidence that mastectomy can have a significant impact on a woman’s psychological adjustment in terms of body image, sexual functioning and relationship with their partners, especially in young women. Schultz and Van de Wiel (2003) found that psychological well-being and sexual intimacy help in the recovery process. This suggests that nurses should be particularly sensitive to the consequences of mastectomy for women’s sexuality and body image, as well as the consequences for their partners. In view of Salter’s study in 1997, it is suggested that nurses consider educating the patients’ husbands about the facial expressions, tone, touch, and behaviour that can enhance their wives’ body image. The nurses should also understand that their own body language can affect their patients’ acceptance of the changes in their body.
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The findings of this review regarding marital adjustment confirmed the need for a comprehensive counseling and education serving the purpose of mental health management for women and partners following mastectomy to facilitate marital adjustment. Patients who reported greater perceived support in a study reported fewer adjustment problems and lower psychological distress (Baidera, Ever-Hadanib, Goldzweigc, Wygodaa, & Peretz, 2003). As such, a good relationship with the husband is important, especially as post-mastectomy outpatient care becomes more common, more men will be involved in providing care and emotional support for their wives at home.
3.2 Recommendations for future research
On the basis of gaps in the current literature, further research is required to find out about the impact of mastectomy on Singaporean women’s body image and sexual functioning.
In the local study, it is found that body image and sexuality is often not discussed with patients following mastectomy as most breast cancer patients felt uneasy talking about their concerns, especially among the Indians, Malays and the elderly Chinese (Saraswathi, Suzanna, & Ho, 2005).
One notable gap in the current literature is an understanding of cultural differences in psychological adjustment which is important to Singapore’s multicultural society. In exploring post-mastectomy body image and sexuality, a nurse should know about customs of different religious groups so she can be culturally sensitive to the women under their care. However, this important area has received limited attention in the published literature.
In the recent years, increasing focus has been given to study the body image among patients following mastectomy (Bakhta, & Najafib, 2010; Moreira, & Canavarro, 2010; Esmaili, Saiidi, Majd, & Esmaieli, 2010). The findings of insignificant changes in body image could be attributed to patients more preoccupied with their survival rather than the physical changes due to loss of the breast in the earlier stages following mastectomy. As such, further study is required to find out the impact on body image after a long period of time when survival is obtained.
Similarly, identification of interventions to respond to women with psychological concerns following mastectomy is yet to be explored. As such, further research is needed to ensure the psychological needs of women are met during treatment.
This literature review details the likelihood of altered body image, the nature of sexual difficulties and the implications of marital adjustment associated with mastectomy. Based on the findings of the review, it is suggested that nurses caring for women who had undergone mastectomy to be particularly sensitive to their sexuality, body image and relationship with their partners to promote better recovery. She may consider teaching the husbands of the women how to help their wives accept their body image changes. In view of the importance of family support, a nurse may want to offer counseling to both the patient and the husband so as to facilitate in the marital adjustment following mastectomy. Several literature gaps are identified, including limited attention to local women’s psychological concerns following mastectomy, customs of different religious groups that may affect the psychological adjustment and effective nursing intervention for women with concerns regarding body image, sexual functioning and marital adjustment following mastectomy.
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