Advertisement

Body acceptance in women with breast cancer: A concept analysis using a hybrid model

Open AccessPublished:January 21, 2023DOI:https://doi.org/10.1016/j.ejon.2023.102269

      Highlights

      • Women with breast cancer undergo drastic bodily changes due to disease and treatment.
      • Body acceptance in women with breast cancer is the key to improving body image.
      • Body acceptance in breast cancer has been conceptualized for the first time.
      • Body acceptance means acknowledging, normalizing, and overcoming physical changes.
      • Body acceptance is identified to directly related to the overall quality of life.

      Abstract

      Background

      Women with breast cancer undergo drastic physical changes which can impact their body image. Accepting the altered body has recently been highlighted as the key to body image improvement, however, there is no clear definition or conceptualization of it. This study clarified the concept of body acceptance in women with breast cancer, using a hybrid model.

      Methods

      In the theoretical phase, the attributes and working definitions of the concept were identified through an extensive literature review. Individual in-depth interviews were conducted during the fieldwork phase to elucidate the concept and verify the attributes derived from the theoretical phase. Finally, in the final analytic phase, the findings were compared and integrated.

      Results

      The theoretical and fieldwork phases included 20 out of the 579 articles extracted from the literature search and five women who had undergone breast cancer surgery, respectively. Body acceptance was defined as “acknowledging, normalizing, and overcoming changes in body appearance and function caused by breast cancer and its treatment”.

      Conclusions

      Body acceptance has been identified as a key factor directly related to the overall quality of life. This study provides a theoretical basis for developing effective interventions and consequently facilitates their provision in practice.

      Keywords

      1. Introduction

      Breast cancer is the most common cancer among women worldwide (
      • Sung H.
      • Ferlay J.
      • Siegel R.L.
      • Laversanne M.
      • Soerjomataram I.
      • Jemal A.
      • Bray F.
      Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      ). As a life-threatening disease (
      • Akram M.
      • Iqbal M.
      • Daniyal M.
      • Khan A.U.
      Awareness and current knowledge of breast cancer.
      ), cancer is accompanied by various symptoms, such as pain and fatigue (
      • Abrahams H.J.G.
      • Gielissen M.F.M.
      • Schmits I.C.
      • Verhagen C.
      • Rovers M.M.
      • Knoop H.
      Risk factors, prevalence, and course of severe fatigue after breast cancer treatment: a meta-analysis involving 12 327 breast cancer survivors.
      ;
      • Forsythe L.P.
      • Alfano C.M.
      • George S.M.
      • Mctiernan A.
      • Baumgartner K.B.
      • Bernstein L.
      • Ballard-Barbash R.
      Pain in long-term breast cancer survivors: the role of body mass index, physical activity, and sedentary behavior.
      ), and causes changes in physical function (
      • Stark L.
      • Tofthagen C.
      • Visovsky C.
      • Mcmillan S.C.
      The symptom experience of patients with cancer.
      ). Mastectomy, the primary treatment for breast cancer, produces irreversible, permanent, and visible changes in women's breasts, which symbolize femininity, sexual attraction, and motherhood (
      • Koéan S.
      • Gþrsoy A.
      Body image of women with breast cancer after mastectomy: a qualitative research.
      ). Systemic treatments, including chemotherapy or radiotherapy to prevent recurrence and metastasis, also result in physical changes, such as alopecia and skin damage (
      • Sebri V.
      • Durosini I.
      • Triberti S.
      • Pravettoni G.
      The efficacy of psychological intervention on body image in breast cancer patients and survivors: a systematic-review and meta-analysis.
      ).
      Drastic physical changes caused by breast cancer and its treatment negatively affect body image (
      • Annunziata M.A.
      • Giovannini L.
      • Muzzatti B.
      Assessing the body image: relevance, application and instruments for oncological settings.
      ). Negative body image among women with breast cancer hinders individual's physical and psychological health (
      • Alhusban R.Y.
      Changed body image as perceived by Jordanian Women undergoing breast cancer treatment.
      ). In addition, it causes changes in relationships with family or partners and social functioning (
      • Fouladi N.
      • Pourfarzi F.
      • Dolattorkpour N.
      • Alimohammadi S.
      • Mehrara E.
      Sexual life after mastectomy in breast cancer survivors: a qualitative study.
      ;
      • Olasehinde O.
      • Arije O.
      • Wuraola F.O.
      • Samson M.
      • Olajide O.
      • Alabi T.
      • Arowolo O.
      • Boutin-Foster C.
      • Alatise O.I.
      • Kingham T.P.
      Life without a breast: exploring the experiences of young Nigerian women after mastectomy for breast cancer.
      ), thereby degrading the quality of life. Therefore, the body image of women with breast cancer is highly emphasized as a predictor of overall quality of life (
      • Wu T.Y.
      • Chang T.W.
      • Chang S.M.
      • Lin Y.Y.
      • Wang J.D.
      • Kuo Y.L.
      Dynamic changes of body image and quality of life in breast cancer patients.
      ).
      Breast cancer survivors adopt various coping strategies in response to physical changes, and their body images varies based on these strategies (
      • Cash T.F.
      • Santos M.T.
      • Williams E.F.
      Coping with body-image threats and challenges: validation of the body image coping strategies inventory.
      ). Women who avoid their altered bodies are reluctant to see or touch their breast, limit social situations where body exposure is expected (
      • Alhusban R.Y.
      Changed body image as perceived by Jordanian Women undergoing breast cancer treatment.
      ), and experience body image distress (
      • Przezdziecki A.
      • Sherman K.A.
      • Baillie A.
      • Taylor A.
      • Foley E.
      • Stalgis-Bilinski K.
      My changed body: breast cancer, body image, distress and self-compassion.
      ). In contrast, body image and quality of life have improved in women who accept body realities without denial as they establish new identities (
      • Yamani Ardakani B.
      • Tirgari B.
      • Roudi Rashtabadi O.
      Body image and its relationship with coping strategies: the views of Iranian breast cancer women following surgery.
      ;
      • Pedersen B.
      • Groenkjaer M.
      • Falkmer U.
      • Delmar C.
      Understanding the essential meaning of measured changes in weight and body composition among women during and after adjuvant treatment for breast cancer: a mixed-methods study.
      ).
      Because an individual's way of coping with physical changes plays a decisive role in forming a body image (
      • Yamani Ardakani B.
      • Tirgari B.
      • Roudi Rashtabadi O.
      Body image and its relationship with coping strategies: the views of Iranian breast cancer women following surgery.
      ), body acceptance, which implies recognizing and accepting the altered body as it is, has been highlighted as the key to improving body image (
      • Stewart T.M.
      Light on body image treatment: acceptance through mindfulness.
      ). Accordingly, various interventions and related studies to promote body acceptance of women with breast cancer have been widely conducted. Consequently, results from such interventions and studies have shown that women's body image and self-esteem improve (
      • Lewis-Smith H.
      • Diedrichs P.C.
      • Harcourt D.
      A pilot study of a body image intervention for breast cancer survivors.
      ).
      However, there is no clear definition or explanation for body acceptance in women within the context of breast cancer. Considering that drastic physical changes are expected after the breast cancer diagnosis (
      • Paterson C.L.
      • Lengacher C.A.
      • Donovan K.A.
      • Kip K.E.
      • Tofthagen C.S.
      Body image in younger breast cancer survivors: a systematic review.
      ) and that acceptance of the altered body is the key factor in both body image and quality of life (
      • Cash T.F.
      • Santos M.T.
      • Williams E.F.
      Coping with body-image threats and challenges: validation of the body image coping strategies inventory.
      ), the concept of body acceptance should be urgently established. Therefore, this study aimed to analyze the attributes and meanings of this concept. This will ultimately improve the quality of life of women with breast cancer by accelerating related research and interventions.

      2. Methods

      A hybrid model of concept analysis is a method that clarifies the concept by combining the theoretical findings of the literature with empirical observations in the field (
      • Schwartz-Barcott D.
      An expansion and elaboration of the hybrid model of concept development.
      ). Considering that body acceptance has not been theoretically conceptualized thus far, and related studies are insufficient, it is essential to explore the given phenomena in women with breast cancer. Therefore, based on the hybrid model (
      • Schwartz-Barcott D.
      An expansion and elaboration of the hybrid model of concept development.
      ), this study analyzed the concept of body acceptance through three phases: theoretical, fieldwork, and the final analytic phase.

      2.1 Theoretical phase

      In the theoretical phase, the attributes and working definition of the concept were derived through a literature review, focusing on “how the concept of body acceptance can be defined and measured” as a key question.

      2.1.1 Search strategy

      The PubMed, CINAHL, EMBASE, PsycInfo, and RISS databases were used for the literature searches. In consultation with the medical librarian, keywords for the literature search were selected: 1) breast neoplasm, 2) body image, and 3) accept* OR adapt* OR adjust* OR copy OR understand* OR understand* OR integrate*. Data were extracted using a combination of keywords by referring to the thesaurus of each database. Because the concept of body acceptance changes with time, only literature published after the 2000s, from January 2000 to October 2021, was included in the analysis. The inclusion criteria were original research on body acceptance, full-text availability, and peer-reviewed journal articles written in English or Korean.

      2.1.2 Search outcome

      As a result of the literature search, 579 articles were extracted. After excluding 201 duplicates, 378 articles were screened in the order of title, abstract, and full text to evaluate whether they met the inclusion criteria and whether the characteristics of the concept could be derived. Finally, 20 articles were selected for the concept analysis (Fig. 1).

      2.2 Fieldwork phase

      In the fieldwork phase, individual in-depth interviews were conducted to clarify the meaning of body acceptance as perceived by female breast cancer survivors, with the concept's attributes identified in the theoretical phase in mind.

      2.2.1 Participants

      • Schwartz-Barcott D.
      An expansion and elaboration of the hybrid model of concept development.
      suggested that sample sizes that facilitate in-depth data analysis are more desirable rather than a large number of samples in the fieldwork phase. In addition, it was recommended to interview three to six people who could reveal the given phenomenon if the subject is an individual unit. Therefore, this study aimed to interview five women with breast cancer and recruited participants through an online breast cancer patient community. With the cooperation of the online community manager, a recruitment notice summarizing the research purpose, methods, and participation requirements was posted.
      The inclusion criterion was women over 18 years of age who had undergone breast cancer surgery. This study limited subjects to those who have passed more than one year after the completion of standard treatment (chemotherapy and radiotherapy), referring that the study on illness acceptance in chronic disease constrained participants to at least one year after diagnosis (
      • Ko I.S.
      • Ji H.J.
      • Hong S.Y.
      • Jung E.Y.
      Concept analysis of illness acceptance in chronic disease: application of hybrid model method.
      ). In addition, those who had undergone surgery or continuous treatment for comorbid diseases other than breast cancer or had a psychiatric history were excluded from the study. Participants’ characteristics expected to affect body acceptance, such as the type of surgery, elapsed period after surgery, and cancer stage at diagnosis, were intended to be evenly included.

      2.2.2 Data collection

      The first author conducted individual in-depth interviews between December 13 and 17, 2021. In consideration of the Coronavirus disease 2019 pandemic, interviews were conducted via zoom. Semi-structured interviews lasted 80 min on average, using interview guides with four main questions: 1) perceptions, emotions, and attitudes toward the altered body; 2) life changes and coping strategies in response to physical changes; 3) the perceived meaning of body acceptance; and 4) antecedents and consequences of body acceptance. All interviews were audio-recorded, with the consent of the participants.

      2.2.3 Data analysis

      The interviews were transcribed verbatim. In addition, non-verbal expressions reflecting participants’ emotions were documented as field notes and referred to in the analysis. Data were analyzed in the following order using a conventional content analysis presented by
      • Hsieh H.F.
      • Shannon S.E.
      Three approaches to qualitative content analysis.
      .
      First, all the data were read repeatedly to have a sense of the whole. Second, words, phrases, and sentences that captured key thoughts were highlighted and labeled to derive codes. Third, the codes were sorted into subcategories depending on their relevance and differences. Fourth, based on the relationships among subcategories, subcategories were compared and combined into upper hierarchical categories. Fifth, definitions were developed for each category and subcategory. Finally, the meaning of body acceptance is illustrated by presenting exemplars for each subcategory reflecting rich content.

      2.2.4 Ethical consideration

      This study was conducted after obtaining approval from the ethics committee of the researchers’ institution (IRB No. Blinded). Subjects interested in this study were asked to contact the researcher directly by referring to the recruitment notice in order to ensure autonomous participation. Prior to the interview, all participants were informed about the purpose and procedure of the study and voluntarily participated with written informed consent. Personal identifiable information was encrypted and kept confidential to maintain anonymity.

      2.3 Final analytic phase

      The attributes and definitions of the concept of body acceptance in women with breast cancer were confirmed by comparing, analyzing, and integrating the findings derived from the theoretical and fieldwork phases.

      3. Results

      3.1 Theoretical phase

      3.1.1 Definitions of body acceptance

      The Oxford English Dictionary (
      • Oxford University Press
      Oxford Learner's Dictionaries.
      ) defines “body” as “the whole physical structure of a human or an animal,” while “acceptance” refers to “the quality of being willing to accept an unpleasant or difficult situation.” Synthesizing these, “body acceptance” can be defined as “a trait that willingly accepts unpleasant or difficult situations in the whole physical structure.” Therefore, body acceptance in women with breast cancer can be interpreted as “a willingness to accept changes in appearance or function caused by breast cancer.”

      3.1.2 Meaning of body acceptance in other disciplines

      Studies on physical changes in women with breast cancer have been conducted, but none have explicitly used the term body acceptance. In addition to nursing, psychology and medicine are disciplines where related research has been conducted extensively.
      Psychologist
      • Kþbler-Ross E.
      • Jãuregui P.
      La Muerte: Un Amanecer.
      presented a grief model consisting of five stages of “denial, anger, bargaining, depression, and acceptance” as the process of condolences for the loss. Acceptance, the last stage in the grief model, refers to restoring psychological stability by coming to terms with a given situation. Similarly, by accepting body realities, women with breast cancer could eliminate negative thoughts and emotions (
      • Lewis-Smith H.
      • Diedrichs P.C.
      • Harcourt D.
      A pilot study of a body image intervention for breast cancer survivors.
      ) and regain confidence (
      • Kurowecki D.
      • Fergus K.D.
      Wearing my heart on my chest: dating, new relationships, and the reconfiguration of self-esteem after breast cancer.
      ) while feeling satisfied with their changed bodies (
      • Herring B.
      • Paraskeva N.
      • Tollow P.
      • Harcourt D.
      Women's initial experiences of their appearance after mastectomy and/or breast reconstruction: a qualitative study.
      ).
      Moreover, breast cancer survivors formed new femininity and identity, rejecting sociocultural standards and pressures on the female body (
      • Grogan S.
      • Mechan J.
      Body image after mastectomy: a thematic analysis of younger women's written accounts.
      ;
      • Thornton M.
      • Lewis-Smith H.
      I listen to my body now": a qualitative exploration of positive body image in breast cancer survivors.
      ;
      • Kurowecki D.
      • Fergus K.D.
      Wearing my heart on my chest: dating, new relationships, and the reconfiguration of self-esteem after breast cancer.
      ). They were proud of scars on the breast as a necessary cost for survival and a sign of victory against cancer (
      • Grogan S.
      • Mechan J.
      Body image after mastectomy: a thematic analysis of younger women's written accounts.
      ). In psychology, body acceptance means overcoming difficulties and negative emotions arising from bodily changes by facing, acknowledging, and fully experiencing them.
      Meanwhile, medicine focuses on accepting the altered body by prioritizing health over physical changes. Women were relieved that they could detect and treat breast cancer. They highly valued survival (
      • Thomas-Maclean R.
      Beyond dichotomies of health and illness: life after breast cancer.
      ) and were grateful for regaining health through tumor resection (
      • Fouladi N.
      • Pourfarzi F.
      • Ali-Mohammadi H.
      • Masumi A.
      • Agamohammadi M.
      • Mazaheri E.
      Process of coping with mastectomy: a qualitative study in Iran.
      ;
      • Olasehinde O.
      • Arije O.
      • Wuraola F.O.
      • Samson M.
      • Olajide O.
      • Alabi T.
      • Arowolo O.
      • Boutin-Foster C.
      • Alatise O.I.
      • Kingham T.P.
      Life without a breast: exploring the experiences of young Nigerian women after mastectomy for breast cancer.
      ). In other words, body acceptance in medicine implies a process in which women with breast cancer positively evaluate physical changes by assigning meaning to treatment.

      3.1.3 Meaning of body acceptance in nursing

      Nursing has viewed body acceptance from the most comprehensive perspective. Women with breast cancer realized that their bodies had irreversibly changed (
      • Freysteinson W.M.
      • Deutsch A.S.
      • Lewis C.
      • Sisk A.
      • Wuest L.
      • Cesario S.K.
      The experience of viewing oneself in the mirror after a mastectomy.
      ;
      • Hill O.
      • White K.
      Exploring women's experiences of TRAM flap breast reconstruction after mastectomy for breast cancer.
      ), fully experienced negative emotions caused by physical changes, and accepted their loss (
      • Chen S.Q.
      • Sun N.
      • Ge W.
      • Su J.E.
      • Li Q.R.
      The development process of self-acceptance among Chinese women with breast cancer.
      ). They also positively interpreted the altered body with more meaning to their survival (
      • Ahn J.H.
      • Suh E.E.
      The lived experience of body alteration and body image with regard to immediate breast reconstruction among women with breast cancer.
      ;
      • Fang S.Y.
      • Balneaves L.G.
      • Shu B.C.
      A struggle between vanity and life": the experience of receiving breast reconstruction in women of Taiwan.
      ) and formed a new identity by breaking away from sociocultural norms (
      • Ahn J.H.
      • Suh E.E.
      The lived experience of body alteration and body image with regard to immediate breast reconstruction among women with breast cancer.
      ;
      • Chuang L.Y.
      • Hsu Y.Y.
      • Yin S.Y.
      • Shu B.C.
      Staring at my body: the experience of body reconstruction in breast cancer long-term survivors.
      ).
      The most notable difference in utilizing the concept in nursing is that it encompasses accepting not only the psychological distress but also the physical changes itself. As women with breast cancer adjusted to the altered body, they felt comfortable with their physical status (
      • Chuang L.Y.
      • Hsu Y.Y.
      • Yin S.Y.
      • Shu B.C.
      Staring at my body: the experience of body reconstruction in breast cancer long-term survivors.
      ) and recognized it as normal (
      • Chen S.Q.
      • Sun N.
      • Ge W.
      • Su J.E.
      • Li Q.R.
      The development process of self-acceptance among Chinese women with breast cancer.
      ). Based on this, they can return to their daily lives and have a positive outlook on their bodies (
      • Ahn J.H.
      • Suh E.E.
      The lived experience of body alteration and body image with regard to immediate breast reconstruction among women with breast cancer.
      ;
      • Hill O.
      • White K.
      Exploring women's experiences of TRAM flap breast reconstruction after mastectomy for breast cancer.
      ).

      3.1.4 Definitive attributes of body acceptance identified in the theoretical phase

      Three definitive attributes of body acceptance were identified as “acknowledgment,” “normalization,” and “overcoming.” Moreover, each was classified into two categories according to the unit of meaning.
      The first attribute, “acknowledgment,” includes two categories: “encountering,” which perceives the altered body smoothly without psychological distress, denial, or avoidance, and “justification,” which accepts physical changes as an inevitable result of breast cancer treatment. The second attribute, “normalization,” consists of two categories: “adaptation,” which involves feeling comfortable and familiar with the altered body, and “return to daily life,” which means performing daily life activities just like before breast cancer diagnosis. Finally, the third attribute, “overcoming,” includes two categories: “successful transition,” which is satisfied with the altered body and rebuilds a new physical identity, and “being optimistic,” which entails having a positive outlook on the body.

      3.1.5 Working definitions of body acceptance identified in the theoretical phase

      By synthesizing the attributes identified in the theoretical phase, body acceptance in women with breast cancer was defined as “acknowledging, normalizing, and overcoming changes in body appearance and function caused by breast cancer and its treatment.”

      3.2 Fieldwork phase

      3.2.1 General and disease-related characteristics of participants

      Five women with breast cancer participated in interviews during the fieldwork phase (Table 1). The mean age of the participants was 44.40 years, and all except one of them, who was 50 years old, were in their 40s. All the participants were college graduates, and three of them were religious. Two out of the five participants were employed, and the perceived socioeconomic status was identified as four in the middle and one in the low. All the participants were married and had at least one child.
      Table 1General and disease-related characteristics of participants in the fieldwork phase.
      CategoriesParticipant No.
      12345
      General characteristics
      Age (year)4345444050
      EducationCollegeCollegeCollegeCollegeCollege
      ReligionNoneBuddhismBuddhismNoneChristian
      EmploymentEmployedEmployedUnemployedUnemployedUnemployed
      Perceived SESMiddleMiddleMiddleLowMiddle
      Marital statusMarriedMarriedMarriedMarriedMarried
      Number of children21212
      Disease-related characteristics
      Cancer stage02210
      Type of surgeryRt. BCORt. BCORt. BRLt. BRRt. MRM
      Postoperative period (year)102531
      History of treatmentsRTx, HTxRTx, CTxCTxCTxHTx
      BCO = breast conserving operation; BR = mastectomy with breast reconstruction; CTx = chemotherapy; HTx = hormone therapy; Lt = left; MRM = modified radical mastectomy; Rt = right; RTx = radiotherapy; SES = socioeconomic status.
      The cancer stage at diagnosis was evenly distributed from Stage 0 to Stage Ⅱ. The types of surgery varied among participants: two underwent a breast-conserving operation, one had a mastectomy without reconstruction, and the other two underwent a mastectomy with immediate breast reconstruction. At the time of the interview, the median postoperative elapsed period was 4.20 years, ranging from a minimum of 1 year to a maximum of 10 years. The participants received treatments, such as chemotherapy, radiotherapy, endocrine therapy, and targeted therapy, depending on the subtype and stage of cancer.

      3.2.2 Meaning of body acceptance derived from the fieldwork phase

      The meaning and degree of body acceptance perceived by the participants varied. As a result of analyzing transcription data using conventional content analysis methods, eight subcategories were derived, which were then integrated into three categories with more abstract and comprehensive meanings.
      • Category 1. Confronting and acknowledging the reality of the altered body
        • 1
          Encountering the altered body wholeheartedly
      Among the various physical changes caused by breast cancer and its treatment, the most significant change the participants encountered was breast resection. Although the degree of change perceived by each person was different, all participants experienced alterations in the appearance and sensation of the breast after surgery. For participants, seeing and touching the operated breast sometimes causes emotional pain. However, participants who did not avoid or turn away from physical changes faced the changed body naturally without fear and upset.Honestly, I hated showering for a while because I must take off my clothes, look in the mirror, and wipe my body. Initially, I could not even touch it. But now, I keep touching and massaging my empty breast to embrace my body. (Patient No. 5)
      • 2
        Understanding physical changes as a treatment process
      In addition to breast resection, the participants experienced treatment-related changes in appearance, such as hair loss and skin pigmentation. Some women experienced tremendous distress, as unbearable as the treatment itself. Moreover, various symptoms occasionally appeared, including pain, fatigue, lymphedema, and menopausal syndrome. However, as breast cancer treatment was an inevitable choice for survival, participants understood the given reality by accepting drastic body changes as a result that had already been expected.Actually, I am not that reluctant to look at my operated breast. I just think, like, “Who cares? I got surgery not because I did something bad but because I was sick.” (Patient No. 1)I heard that pain or fatigue might be experienced after chemotherapy. So, I am accepting it as “this is just an aftereffect of the treatment.” (Patient No. 3)
      • 3
        Soothing one's distress
      The participants explored their bodies again, while valuing survival and health more than physical changes. Although the breast was deformed, women consoled themselves that they were freed from the risk of recurrence or metastasis as the cancer was also eradicated. In addition, participants were grateful that the physical changes were not as significant as they had previously anticipated, and even regarded it as “fortunate that it’s just to this extent” by comparing it to others who suffered more. This way, participants comforted their hurt minds by positively interpreting the given situation.If this is the result of cosmetic surgery, it is a big problem for which the hospital needs to be held accountable. However, it was a matter that was directly related to my life, so I accepted it, thinking, “though, it has shaped the part that was supposed to be cut out because of cancer surgery.” (Patient No. 4)When I meet patients around me, I think, “Oh, she is that sick. I am glad I am not that sick.” (Patient No. 2)
      • Theme 2. Resuming daily life in harmony with the altered body
        • 1
          Learning ways to live with one's altered body
      The participants devised their strategies in response to their altered physical conditions. When physical strength decreased or symptoms appeared due to the progression of cancer and side effects of treatment, they adjusted the level of activity so that the body did not strain. In addition, women utilized accessories, including underwear, wigs, or hats, to compensate for noticeable changes in appearance, such as breast deformation and hair loss. Thus, the participants learned and practiced a new way of living in person.Considering my physical condition, I try to refrain from extreme exercise and replace it with walking or other activities. I have lymphedema, so I perform arm exercises regularly and check the difference between both arms every evening after the shower. (Patient No. 3)I prepared my heart for hair loss before initiating chemotherapy. After my hair fell out, I tried to find out how to make it more natural, rather than being sad about “Why did I become like this?” (Patient No. 1)
      • 2
        Feeling comfortable with physical changes
      As participants got used to the altered body, the discomfort following physical changes also decreased. In particular, as women became numb to changes in the appearance and sensation of their breasts, the time they were unconscious that they had undergone breast cancer surgery lengthened. Participants expressed they were accustomed to their bodies to the extent that “I forget I am a breast cancer patient,” if there were no physical symptoms, such as intermittent pain.When I did not feel pain, I thought there was no discomfort. Only when I could not lift something heavy did I think, “Oh, right. I had breast cancer surgery.” Then, after a while, I forgot about it again, so I think I have accepted my body well. (Patient No. 4)
      • 3
        Returning to one's ordinary life
      Despite the restrictions caused by physical changes, participants’ lives continued. Although this was not the same as before, the participants returned to their daily lives. Despite the large and small difficulties, participants evaluated themselves as able to perform their roles and functions like others. As daily life, which seemed to change entirely due to physical changes, gradually regained stability, the participants began to recognize their bodies as normal.Compared to the past, it has only changed almost externally, and there is no inconvenience in activities or life. Now that I can do everything I used to do like others, so I think, “I am the same as anyone else.” (Patient No. 5)
      • Theme 3. Embracing bodily changes and designing a healthy future
        • 1
          Regaining confidence and being satisfied with one's body
      The participants appreciated their bodies, focusing on what they could still do rather than what they had lost due to physical changes. As women regained confidence regarding their bodies, they became unconscious of how others would perceive them. Participants no longer tried to hide their changed bodies, but naturally appeared in front of others. In addition, women were satisfied with their physical condition, deviating from the sociocultural standards for women's bodies that they had idealized before cancer diagnosis.Actually, I do not feel my scar is ugly but more thankful. I do not think it is terrible, so I can talk freely about it rather than hide it. (Patient No. 1)Before I developed breast cancer, I seriously considered breast augmentation surgery. In the past, appearance and breast size were important to me. However, now it does not matter at all. I think, “It's okay as it is.” (Patient No. 2)
      • 2
        Taking care of the body consistently for a healthier future
      Participants who realized the importance of health through illness experience began to pay attention to their bodies and actively managed them. While improving their lifestyle, some participants expressed that they felt “rather healthier” than before their breast cancer diagnosis. Participants recognized breast cancer as a threat to their lives and an opportunity to leap into a healthier future simultaneously. Participants designed a new life by practicing health-promoting behaviors through a positive outlook on their bodies.I used to say, “I am glad I got breast cancer.” Thanks to breast cancer, I have regular check-ups like this, which makes it easier to screen and treat any other disease in the long term. Therefore, I believe that “Breast cancer is not necessarily bad, because it will lead to a healthier life.” (Patient No. 1)I think I am working hard. I strictly control my diet and exercise daily. So my close friends say, “You are incredible to manage your health like it in a textbook way.” (Patient No. 5)

      3.3 Final analytic phase

      3.3.1 Comparison and integration of findings from theoretical and fieldwork phases

      The three attributes identified in the theoretical phase, “acknowledgment,” “normalization,” and “overcoming,” were similarly derived in the fieldwork phase as “confronting and acknowledging the reality of the altered body,” “resuming daily life in harmony with the altered body,” and “embracing bodily changes and designing a healthy future.” In detail, six categories, two each from three attributes, were identified in the theoretical phase, and eight subcategories were derived from three categories in the fieldwork phase (Table 2).
      Table 2The result of the concept analysis at each phase.
      Theoretical phaseFieldwork phaseFinal analytic phase
      AcknowledgmentConfronting and acknowledging the reality of the altered bodyAcknowledgment
      EncounteringEncountering the altered body wholeheartedlyEncountering
      JustificationUnderstanding physical changes as a treatment process Soothing one's distressUnderstanding
      NormalizationResuming daily life in harmony with the altered bodyNormalization
      AdaptationLearning ways to live with one's altered body Feeling comfortable with physical changesAdaptation
      Return to daily lifeReturning to one's ordinary lifeReturn to daily life
      OvercomingEmbracing bodily changes and designing a healthy futureOvercoming
      Successful transitionRegaining confidence and being satisfied with one's bodySuccessful transition
      Being optimisticTaking care of the body consistently for a healthier futureLeap into the future
      Note. Underlined text indicates the differences or changes among the theoretical, fieldwork, and final analytic phases.
      Based on the attributes of the theoretical phase, “encountering,” a subcategory of the first attribute, “acknowledgment,” was identified as “encountering the altered body wholeheartedly” during the fieldwork phase. In addition, “justification” in the theoretical phase was identified as “understanding physical changes as a treatment process” in the fieldwork phase. In a similar context, “soothing one's distress” emerged from the fieldwork phase. These were integrated and revised as “understanding.”
      The second attribute of the theoretical phase, “adaptation,” a subcategory of “normalization,” was identified as “feeling comfortable with physical changes” during the fieldwork phase. In the fieldwork phase, “learning ways to live with one's altered body” was added as a response to body change, and it was integrated into “adaptation” in consideration of the similarity of the contents. The “return to daily life” in the theoretical phase was confirmed as “returning to one's ordinary life” in the fieldwork phase.
      “Successful transition,” a subcategory of “overcoming,” the third attribute of the theoretical phase, was identified as “regaining confidence and being satisfied with one's body” during the fieldwork phase. On the other hand, in the theoretical phase, “being optimistic,” indicating a positive outlook for the body, was identified. In response, “taking care of the body consistently for a healthier future” was derived in the fieldwork phase, which practices health promotion behaviors based on positive prospects. Considering the comprehensiveness of the contents, these were integrated and revised as “leap into the future.”

      3.3.2 Final attributes of body acceptance

      The results were derived by comparing and synthesizing the attributes and meanings of body acceptance identified in the theoretical and fieldwork phases. The attributes and categories of body acceptance confirmed during the final analytic phase are listed in Table 3.
      Table 3Attributes of body acceptance in women with breast cancer confirmed in the final analytic phase.
      AttributesCategoriesDescription
      AcknowledgmentEncounteringPerceiving the altered body smoothly without psychological distress, denial, or avoidance
      UnderstandingConsoling oneself by accepting physical changes as a process of breast cancer treatment
      NormalizationAdaptationCoping with physical changes properly and feeling comfortable with the altered body
      Return to daily lifePerforming daily life without restrictions due to physical changes
      OvercomingSuccessful transitionRestoring confidence in the body and embracing the altered body
      Leap into the futureActively managing body with a positive outlook on the body

      3.3.3 Final definition of body acceptance

      Based on the above analysis results, body acceptance among women with breast cancer was defined as “acknowledging, normalizing, and overcoming changes in body appearance and function caused by breast cancer and its treatment.”

      4. Discussion

      This study applied Schwartz-Barcott and Kim (2000)'s hybrid model to clarify the concept of body acceptance and to understand the given phenomena in the context of breast cancer. Through the theoretical, fieldwork, and final analytic phases, it was defined as “acknowledging, normalizing, and overcoming changes in body appearance and function caused by breast cancer and its treatment.” In other words, the body acceptance of women with breast cancer implies encountering and understanding the body realities resulting from disease and treatment, returning to daily life by adapting to physical changes, and leaping into a healthier future through a successful transition to the altered body.
      • Cash T.F.
      • Santos M.T.
      • Williams E.F.
      Coping with body-image threats and challenges: validation of the body image coping strategies inventory.
      presented positive rational acceptance as a coping strategy in response to body image distress. This means embracing challenging events with positive self-care or rational self-talk instead of avoiding body image threats or concealing perceived defects.
      • Sandoz E.K.
      • Wilson K.G.
      • Merwin R.M.
      • Kate Kellum K.
      Assessment of body image flexibility: the body image-acceptance and action questionnaire.
      proposed the concept of body image flexibility, which refers to the whole and intentional experience of perceptions, thoughts, beliefs, and emotions regarding one's body, rather than trying to alter it. As such, the concepts related to body acceptance developed in general population tend to be limited to “acknowledgment” among the attributes derived in this study.
      However, body acceptance among women with breast cancer implies adapting to the altered body and actively managing it beyond allowing psychological distress (
      • Chuang L.Y.
      • Hsu Y.Y.
      • Yin S.Y.
      • Shu B.C.
      Staring at my body: the experience of body reconstruction in breast cancer long-term survivors.
      ). These results can be interpreted in relation to the fact that body image alteration in cancer patients is not due to distorted perceptions of the shape and size of the body, as in the general population (
      • Thompson J.K.
      • Stice E.
      Thin-ideal internalization: mounting evidence for a new risk factor for body-image disturbance and eating pathology.
      ), but is the result of actual physical changes caused by disease and treatment (
      • Fingeret M.C.
      • Teo I.
      • Epner D.E.
      Managing body image difficulties of adult cancer patients: lessons from available research.
      ). In other words, not only acknowledging negative perceptions of the body but also normalizing and overcoming body realities is a key factor in body acceptance.
      Meanwhile, in studies on illness acceptance in general and chronically ill adults, disease experience and management, such as understanding disease, overcoming limitations, and designing a new life through self-care, were confirmed as core attributes (
      • Ko I.S.
      • Ji H.J.
      • Hong S.Y.
      • Jung E.Y.
      Concept analysis of illness acceptance in chronic disease: application of hybrid model method.
      ;
      • Zheng K.
      • Bruzzese J.M.
      • Smaldone A.
      Illness acceptance in adolescents: a concept analysis.
      ). Similarly, the concept of body acceptance in women with breast cancer also includes elements of illness acceptance due to experiences of fatal diseases. However, this study also connotes acknowledging and compensating for the changes in appearance and restoring self-confidence. This reflects the disease-specific nature of breast cancer, which is accompanied by visible and irreversible changes in the body parts that symbolize sexual attraction and motherhood (
      • Koéan S.
      • Gþrsoy A.
      Body image of women with breast cancer after mastectomy: a qualitative research.
      ).
      In summary, body acceptance of women with breast cancer is a concept that encompasses accepting changes in body appearance and function caused by disease and treatment. It has unique properties that distinguish it from adjacent concepts, such as body acceptance of the general population or illness acceptance of patients with chronic diseases. To date, conceptualization related to physical changes in the oncology sphere has mainly focused on negative body images (
      • Lehmann V.
      • Hagedoorn M.
      • Tuinman M.A.
      Body image in cancer survivors: a systematic review of case-control studies.
      ). In a situation where interest in positive body images has recently increased and related research has begun to emerge (
      • Thornton M.
      • Lewis-Smith H.
      I listen to my body now": a qualitative exploration of positive body image in breast cancer survivors.
      ), this study examining body acceptance is considered timely.

      4.1 Limitations

      The literature search in the theoretical phase was rigorously conducted; however, it was restricted to articles written in English or Korean. This may have omitted the meaningful information associated with body acceptance in women with breast cancer. The number of participants in the fieldwork phase was determined based on suggestions regarding the sample size of the hybrid model (
      • Schwartz-Barcott D.
      An expansion and elaboration of the hybrid model of concept development.
      ). Although the findings of the interviews emerged from relatively small samples, the authors determined that it was sufficient to reach saturation for qualitative analysis and provide insights into the concept of body acceptance.

      4.2 Implications for research and clinical practice

      This study is of great significance because it conceptualized body acceptance by reflecting the unique characteristics of women with breast cancer, rather than simply borrowing concepts developed in other populations or disciplines. One thing to note is that, contrary to conventional wisdom, body acceptance is not a consecutive process in a specific order from “acknowledgment” to “overcoming,” and that a certain period does not guarantee body acceptance. Therefore, exploring an individual's unique body experience is essential rather than assuming it to be uniform. This will ultimately improve the quality of life of women with breast cancer by providing useful information for devising tailored interventions to promote body acceptance.

      5. Conclusion

      This study derives the definition and attributes of the concept of body acceptance by applying a hybrid model. As a result of conceptual analysis, body acceptance among women with breast cancer was defined as “acknowledging, normalizing, and overcoming changes in body appearance and function caused by breast cancer and its treatment.” In the context of breast cancer, body acceptance has been identified as a vital factor directly related to psychological and physical health and quality of life.
      These results broaden our understanding of a given phenomenon and provide a theoretical basis for future research. Further studies exploring the factors influencing body acceptance are required to develop effective strategies for relevant interventions.

      Author contributions

      Jeonghee Ahn: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – Original draft Eunyoung E. Suh: Supervision, Funding acquisition, Project administration, Writing – Review & Editing.

      Funding

      This research was supported by the BK21 four project (Center for Human-Caring Nurse Leaders for the Future) funded by the Ministry of Education and National Research Foundation of Korea.

      Declaration of competing interest

      The authors have no conflicts of interest to disclose.

      Acknowledgments

      The authors sincerely thank all the women for sharing their valuable experiences in this study. A summary of this paper was presented at a poster session of the Global Breast Cancer Conference 2022.

      References

        • Abrahams H.J.G.
        • Gielissen M.F.M.
        • Schmits I.C.
        • Verhagen C.
        • Rovers M.M.
        • Knoop H.
        Risk factors, prevalence, and course of severe fatigue after breast cancer treatment: a meta-analysis involving 12 327 breast cancer survivors.
        Ann. Oncol. 2016; 27: 965-974
        • Ahn J.H.
        • Suh E.E.
        The lived experience of body alteration and body image with regard to immediate breast reconstruction among women with breast cancer.
        J. Kor. Acad. Nurs. 2021; 51: 245-259
        • Akram M.
        • Iqbal M.
        • Daniyal M.
        • Khan A.U.
        Awareness and current knowledge of breast cancer.
        Biol. Res. 2017; 50: 33
        • Alhusban R.Y.
        Changed body image as perceived by Jordanian Women undergoing breast cancer treatment.
        Asian Pac. J. Cancer Prev. 2019; 20: 767-773
        • Annunziata M.A.
        • Giovannini L.
        • Muzzatti B.
        Assessing the body image: relevance, application and instruments for oncological settings.
        Support. Care Cancer. 2012; 20: 901-907
        • Cash T.F.
        • Santos M.T.
        • Williams E.F.
        Coping with body-image threats and challenges: validation of the body image coping strategies inventory.
        J. Psychosom. Res. 2005; 58: 190-199
        • Chen S.Q.
        • Sun N.
        • Ge W.
        • Su J.E.
        • Li Q.R.
        The development process of self-acceptance among Chinese women with breast cancer.
        Jpn. J. Nurs. Sci. 2020; 17e12308
        • Chuang L.Y.
        • Hsu Y.Y.
        • Yin S.Y.
        • Shu B.C.
        Staring at my body: the experience of body reconstruction in breast cancer long-term survivors.
        Cancer Nurs. 2018; 41: E56-E61
        • Fang S.Y.
        • Balneaves L.G.
        • Shu B.C.
        A struggle between vanity and life": the experience of receiving breast reconstruction in women of Taiwan.
        Cancer Nurs. 2010; 33: E1-E11
        • Fingeret M.C.
        • Teo I.
        • Epner D.E.
        Managing body image difficulties of adult cancer patients: lessons from available research.
        Cancer. 2014; 120: 633-641
        • Forsythe L.P.
        • Alfano C.M.
        • George S.M.
        • Mctiernan A.
        • Baumgartner K.B.
        • Bernstein L.
        • Ballard-Barbash R.
        Pain in long-term breast cancer survivors: the role of body mass index, physical activity, and sedentary behavior.
        Breast Cancer Res. Treat. 2013; 137: 617-630
        • Fouladi N.
        • Pourfarzi F.
        • Ali-Mohammadi H.
        • Masumi A.
        • Agamohammadi M.
        • Mazaheri E.
        Process of coping with mastectomy: a qualitative study in Iran.
        Asian Pac. J. Cancer Prev. 2013; 14: 2079-2084
        • Fouladi N.
        • Pourfarzi F.
        • Dolattorkpour N.
        • Alimohammadi S.
        • Mehrara E.
        Sexual life after mastectomy in breast cancer survivors: a qualitative study.
        Psycho Oncol. 2018; 27: 434-441
        • Freysteinson W.M.
        • Deutsch A.S.
        • Lewis C.
        • Sisk A.
        • Wuest L.
        • Cesario S.K.
        The experience of viewing oneself in the mirror after a mastectomy.
        Oncol. Nurs. Forum. 2012; 39: 361-369
        • Grogan S.
        • Mechan J.
        Body image after mastectomy: a thematic analysis of younger women's written accounts.
        J. Health Psychol. 2017; 22: 1480-1490
        • Herring B.
        • Paraskeva N.
        • Tollow P.
        • Harcourt D.
        Women's initial experiences of their appearance after mastectomy and/or breast reconstruction: a qualitative study.
        Psycho Oncol. 2019; 28: 2076-2082
        • Hill O.
        • White K.
        Exploring women's experiences of TRAM flap breast reconstruction after mastectomy for breast cancer.
        Oncol. Nurs. Forum. 2008; 35: 81-88
        • Hsieh H.F.
        • Shannon S.E.
        Three approaches to qualitative content analysis.
        Qual. Health Res. 2005; 15: 1277-1288
        • Ko I.S.
        • Ji H.J.
        • Hong S.Y.
        • Jung E.Y.
        Concept analysis of illness acceptance in chronic disease: application of hybrid model method.
        J. Kor. Acad. Fund. Nurs. 2021; 28: 67-82
        • Koéan S.
        • Gþrsoy A.
        Body image of women with breast cancer after mastectomy: a qualitative research.
        J. Breast Health. 2016; 12: 145-150
        • Kþbler-Ross E.
        • Jãuregui P.
        La Muerte: Un Amanecer.
        Ediciones Luciérnaga, Barcelona2008
        • Kurowecki D.
        • Fergus K.D.
        Wearing my heart on my chest: dating, new relationships, and the reconfiguration of self-esteem after breast cancer.
        Psycho Oncol. 2014; 23: 52-64
        • Lehmann V.
        • Hagedoorn M.
        • Tuinman M.A.
        Body image in cancer survivors: a systematic review of case-control studies.
        J. Cancer Surv. 2015; 9: 339-348
        • Lewis-Smith H.
        • Diedrichs P.C.
        • Harcourt D.
        A pilot study of a body image intervention for breast cancer survivors.
        Body Image. 2018; 27: 21-31
        • Olasehinde O.
        • Arije O.
        • Wuraola F.O.
        • Samson M.
        • Olajide O.
        • Alabi T.
        • Arowolo O.
        • Boutin-Foster C.
        • Alatise O.I.
        • Kingham T.P.
        Life without a breast: exploring the experiences of young Nigerian women after mastectomy for breast cancer.
        J. Glob. Oncol. 2019; 5: 1-6
        • Oxford University Press
        Oxford Learner's Dictionaries.
        ([Online]. Available:)
        https://www.oxfordlearnersdictionaries.com/
        Date: 2022
        Date accessed: October 18, 2022
        • Paterson C.L.
        • Lengacher C.A.
        • Donovan K.A.
        • Kip K.E.
        • Tofthagen C.S.
        Body image in younger breast cancer survivors: a systematic review.
        Cancer Nurs. 2016; 39: E39-E58
        • Pedersen B.
        • Groenkjaer M.
        • Falkmer U.
        • Delmar C.
        Understanding the essential meaning of measured changes in weight and body composition among women during and after adjuvant treatment for breast cancer: a mixed-methods study.
        Cancer Nurs. 2017; 40: 433-444
        • Przezdziecki A.
        • Sherman K.A.
        • Baillie A.
        • Taylor A.
        • Foley E.
        • Stalgis-Bilinski K.
        My changed body: breast cancer, body image, distress and self-compassion.
        Psycho Oncol. 2013; 22: 1872-1879
        • Sandoz E.K.
        • Wilson K.G.
        • Merwin R.M.
        • Kate Kellum K.
        Assessment of body image flexibility: the body image-acceptance and action questionnaire.
        J. Contextual Behav. Sci. 2013; 2: 39-48
        • Schwartz-Barcott D.
        An expansion and elaboration of the hybrid model of concept development.
        Concept Dev. Nurs. Found. Techn. Appl. 2000; : 129-159
        • Sebri V.
        • Durosini I.
        • Triberti S.
        • Pravettoni G.
        The efficacy of psychological intervention on body image in breast cancer patients and survivors: a systematic-review and meta-analysis.
        Front. Psychol. 2021; 12611954
        • Stark L.
        • Tofthagen C.
        • Visovsky C.
        • Mcmillan S.C.
        The symptom experience of patients with cancer.
        J. Hospice Palliat. Nurs. 2012; 14: 61-70
        • Stewart T.M.
        Light on body image treatment: acceptance through mindfulness.
        Behav. Modif. 2004; 28: 783-811
        • Sung H.
        • Ferlay J.
        • Siegel R.L.
        • Laversanne M.
        • Soerjomataram I.
        • Jemal A.
        • Bray F.
        Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J. Clin. 2021; 71: 209-249
        • Thomas-Maclean R.
        Beyond dichotomies of health and illness: life after breast cancer.
        Nurs. Inq. 2005; 12: 200-209
        • Thompson J.K.
        • Stice E.
        Thin-ideal internalization: mounting evidence for a new risk factor for body-image disturbance and eating pathology.
        Curr. Dir. Psychol. Sci. 2001; 10: 181-183
        • Thornton M.
        • Lewis-Smith H.
        I listen to my body now": a qualitative exploration of positive body image in breast cancer survivors.
        Psychol. Health. 2021; : 1-20
        • Wu T.Y.
        • Chang T.W.
        • Chang S.M.
        • Lin Y.Y.
        • Wang J.D.
        • Kuo Y.L.
        Dynamic changes of body image and quality of life in breast cancer patients.
        Cancer Manag. Res. 2019; 11: 10563-10571
        • Yamani Ardakani B.
        • Tirgari B.
        • Roudi Rashtabadi O.
        Body image and its relationship with coping strategies: the views of Iranian breast cancer women following surgery.
        Eur. J. Cancer Care. 2020; 29e13191
        • Zheng K.
        • Bruzzese J.M.
        • Smaldone A.
        Illness acceptance in adolescents: a concept analysis.
        Nurs. Forum. 2019; 54: 545-552