Body image and breast cancer: a resource for women

The term body image refers to our thoughts, feelings and overall attitude around how we look, how we feel and the way our body works. All around us, we hear and see messages about what a woman should look like and how she should be and act. These messages affect our body image.

Breast cancer and its treatment can have a negative impact on your body image.

In the video above and the resources below, find out more about body image, how breast cancer can affect your body image, and some strategies to help if your body image after breast cancer is negatively affecting your quality of life.

This video and web resources are designed for women who have completed treatment for breast cancer. Some topics and issues mentioned below will be addressed in greater depth in future web resources that will include many more helpful tips and suggestions. If you are experiencing challenges with body image or other have other concerns during or after your treatment, please reach out to your care team.

This resource was developed with input from women facing breast cancer.

What is body image and how can breast cancer and its treatment affect it?

Body image includes our thoughts, feelings and our overall attitude about our physical appearance. It also includes feelings and perceptions related to how our body functions. Our perception of our overall health and wholeness, our sense of “who we are” in the world, our sexuality, and our self-esteem, are all part of body image. Breast cancer and its treatment can have a major impact on all of these things.

Dealing with breast cancer, in many ways, is about loss

It is common for women to feel less feminine or generally less confident.

Dissatisfaction with one’s “new” body and lowered self-esteem may change the woman’s ability to enjoy sexual intimacy, and even affect her general social interactions. Some women report feeling generally less effective at carrying out their numerous roles (e.g. as a mother, spouse or member of the work force).

A diagnosis of breast cancer is life-altering for many people

The changes and losses can be felt to be life-altering and lead a person to feel uncertain about, or different in, who they are as a person. For example, prior beliefs about one’s self, such as “I’m a healthy person”, or “I’m strong”, or “I value my work” can feel very different after a cancer diagnosis. These identity shifts can feel really surprising and really challenging to a person’s sense of themselves.

The physical and emotional changes can lead a woman to feel broken or that her life has been interrupted. These experiences are normal reactions to the breast cancer experience, and they require some time for adjustment. Every woman will encounter some changes, and these changes need to be integrated into her sense of herself and her body, towards an increased feeling of wholeness as she continues on with her life.

Your body image after breast cancer

The degree to which a woman’s body is altered after treatment will clearly affect her body image. For example, a woman who has had a mastectomy (especially without reconstruction) will have a greater change in body image than the woman who has had a lumpectomy with less of a significant change to the appearance of her breast.

In addition, there are many factors related to a woman’s life before cancer that contribute to the way she feels about her body and her sense of self after cancer.

View factors that contribute to your body image

Identity

Women come to the breast cancer experience with a deeply ingrained set of beliefs and personal values regarding their life’s purpose and, more specifically, the roles and characteristics that define them. Some of these beliefs come from their upbringing — their culture and family — and are reinforced by society, including social networks, social media, and peers. Other beliefs are fostered by experiences, accomplishments and lifestyle. These ideas about self, and how strongly they are held, will affect how women cope and adjust to breast cancer.

As a woman returns to her normal routines and life it can be more difficult if she, or other, expect her to be able to function in exactly the same way that she functioned before cancer, especially when there are irreversible effects of treatment or ongoing changes in functioning (e.g. cognitive difficulties, premature menopause or altered sexual interest).

For you, this might mean you no longer have the same stamina to stay up half the night cooking and baking for your family, or to be the employee who always works overtime as well as on weekends. You may no longer feel as physically attractive or be sexually aroused as easily, or be able to give birth to biological children. You may feel that you have failed to meet some womanly standard in relation to your sense of being a woman, in carrying out the roles that you have. Challenges in returning to activities may leave you to feeling more negative about your body, or less self-confident.

Investment in physical appearance or health

How much a woman values and invests in her physical appearance prior to breast cancer can play a role in adjustment after breast cancer. For example, how much emphasis she places on her physical appearance or how much it plays a role in determining her happiness, personal satisfaction and well-being, can affect a woman’s ability to move forward after breast cancer. People vary on this factor. A woman who placed a lot of focus on her appearance and how it made her feel good about herself before breast cancer, is more likely to find that treatment-related changes to her appearance negatively affect her emotional well-being.

Similarly, a woman who, in the past, was meticulous about exercise and healthy eating often feels betrayed by developing cancer, and may feel devastated if, after treatment, she is unable to return to her pre-treatment body shape or level of physical stamina.

Stereotypes of femininity and attractiveness

Cultural and societal influences that shape how women think about and view themselves strongly affect how they feel about their bodies. In fact, these influences can set a kind of “standard” of what is considered beautiful or ideal for a woman. While “ideals” vary by culture, most Western societies have an ideal continuously seen in media and advertisements, and that may leave women feeling pressured to meet these standards.

Some influences are direct, like “ideal forms of beauty” depicted in magazines, Instagram, and on other social media. However, other influences are much more indirect in how they are communicated. These influences can be just as powerful and are all over. You might have experienced this when a friend or partner only comments favourably on your appearance when your apply make-up or have your hair styled professionally.

Women who identify with traditional notions of femininity or attractiveness sometimes feel a sense of shame when they cannot return to a level of physical appearance that they had prior to breast cancer experience. This is especially true if there are obvious visible physical changes (e.g., loss of breast, physical scarring, hair loss, lymphedema).

Further reading on this topic: “Too Good For Her Own Good written by Claudia Bepko and Jo-Ann Krestan (1991). This book helps women to see the layers of sociocultural influences in Western society that can impact how a woman feels about her body and her sense of self.

Am I being too hard on myself?

You might find yourself inspecting or constantly self-monitoring your body and your functioning. This may involve routinely comparing your body to a former sense of how it looked or felt. It might also involve comparisons to ideals in the media or among social networks or peers. Similarly, there can be frequent comparisons of how you are able to return to specific activities (or not) in your life. When this type of self- monitoring is continuous or frequent, it can make you feel that you don’t measure up (to where you “should be” or “expect to be”).

It is not uncommon for women to have strong negative feelings, such as embarrassment, shame or disgust, about their bodies. They may avoid looking at themselves in a mirror or to attempt to hide their body shape in less form-fitting clothing. Sometimes women avoid shopping for new clothing, or stop doing a sport or social activity that they previously enjoyed.

Feelings of shame or unacceptance can be very bothersome, and get in the way of daily living and activities that would likely bring you pleasure. This can happen even though there may be no medical reason why you cannot return to these activities. For example, swimming can be resumed, although it may require exploring and finding a new style of a bathing suit or bra that can work with your new body.

These feelings or changes in behaviour may be indicative of negative body image and can affect women getting back on track after breast cancer.

What you may not realize is that you may have pretty high standards, even perfectionistic standards, in relation to how you feel you should be or look. The constant self-monitoring or negative thoughts about yourself are hard on you, and will affect your emotional well-being. You may even have a supportive partner or friends telling you that they value you as you are, or that you are still very attractive, or that they wish to be with you, and yet you find yourself disagreeing with their perspective. You may even believe they are just trying to make you feel better about yourself.

This mindset can also interfere with intimacy. Constant negative feelings about your body or performance make it much more difficult to relax during sexual intimacy. Embarrassment, other negative feelings or new changes (e.g. vaginal dryness) may lead to avoiding intimate relations, even with a supportive, caring partner. Common signs of difficulty include avoiding looking in a mirror or undressing in the presence of others, including an intimate partner. Women who are not partnered may be hesitant to try dating, even if there is interest by others. And some women may spend more time alone, preferring to avoid any social events.

Do you find yourself thinking things like:

"If I don’t accomplish everything I should, then I must be a failure"
"Whenever I see media pictures of women, I feel dissatisfied with my body"
"I can’t feel good about myself unless I feel physically attractive or get back to how I looked before"
“I feel like I must be a bad person when I don’t look as good as I could."
"I think a person can look pretty much how they want to if they are willing to work at it."

These kinds of comments might suggest that there is a lot of value placed on your appearance, and a strong need to get back a prior self. If you find yourself thinking these kinds of thoughts, remember, you are not alone. Also remember, there are ways to move forward.

How can I move forward?

Let your health-care team or other women with cancer know that you are having difficulty or avoiding activities that you used to enjoy. They can help you find support and learn new ways to get a better sense of well-being and balance as you move forward.

More tips, information and strategies

Take the time to explore new ideas of who you are now, and to think about the new things that you have discovered about yourself as you came through the experience of having breast cancer. You may have discovered some new areas of strength that you didn’t realize before. Or you may come to value different activities or come to see new views of your own personal standards of what is “beautiful” or important. Finding new notions of what is important or ideal for you may become more realistic, and your supports or the health team can also help you explore what is achievable too.

Once you identify which messages about "what it means to be a woman," and which standards of beauty are internalized from the media and other influences around us, you are more able to consciously choose your own relevant standard, based on your values and what is important to you. Recognizing that your new standards are no less — and probably more — valid than previous ones, will help you make the necessary changes that you wish to make, and move forward in your adjustment.

Perhaps most importantly, you can give yourself the time and permission to replace the notion of always needing to "do good" for others, if that has been a theme in your life, to instead to devote some time and effort to "feeling good" for yourself.

Here are some steps that can help facilitate reconnecting to your body after breast cancer:

Try to identify those harmful messages from the media, our culture, friends and family about the female body. Try to reflect on which of these messages are now influencing you. How do you feel about them as you reflect? Do you think they are placing pressure on you to conform to some specific way of looking, or being as a person?

Try to use a more women-centered and nurturing approach in considering your own sense of self. For example, try thinking in a critical way about these external messages and what they are really saying. For example, you might begin by questioning the notion that there is one “right” body type, or that women’s bodies need to be constantly fixed, altered and take up less space. Consider whether those who spread these messages and encourage these ways of thinking have women’s best interests in mind.

In order to move forward it is helpful to "rebuild" your sense of self by getting to know yourself now and redefining who you are, especially as you may have discovered new things about yourself. Think about or write about what the breast cancer experience has brought to you. What did you learn about yourself? What do you find yourself wanting or valuing now? What does femininity, beauty or health mean to you after going through treatment for breast cancer? What do you find is important now in bringing you happiness?

Be kind and more compassionate to yourself and try to find time for some daily self-compassion. You have been through so much.

Try to find ways to actively engage with, move, and feel better about your body. Be open to new ways of knowing your body and experiencing it as more than merely an object to be looked at. With a supportive friend or family member, explore new things and discover which activities are important to you and that you enjoy. There is a whole range of activities that help us to reconnect our minds to our bodies, or that help us to physically feel and enjoy our physical selves. Examples include: yoga, meditation, going for a walk, swimming, cycling, dancing, sports.

Lastly, be sure to let your health care team, loved ones, or other women with cancer know if you are continuing to struggle with these issues. Seeking out social support from your community and/or psychological support from a trained mental health professional can help you get back on track, find better balance in your life, and to feel less alone.

Activity: Guided imagery exercises

These exercises may bring out strong feelings and emotions. If at any time you feel too uncomfortable to continue, please stop the exercise. After the exercise, you may want to write down your thoughts in a journal. If you have questions or concerns after the exercise, please contact your care team or PYNK.

1. Inner sanctuary

» View a text version of the inner sanctuary guided imagery exercise

This is an exercise through which I will guide you. Just follow the instructions on the tape.

Let's begin by just counting slowly to yourself, focusing on your breathing from one up towards 10. And as you do so, allow each breath to become slower and deeper, slower and deeper. And just allow yourself to become more and more relaxed. As you approach 10. Letting any tension from the day just leave your body as you breathe outward, feeling more and more calm, more relaxed.

Letting your body feel lighter and freer.

As we approach 10, noticing the breathing in and out of your lungs. Just feeling more and more relaxed, even feeling calm.

I want you to imagine some special place of your choice, where it feels pleasant to be. It could be outside in a meadow or by water. It could even be a special room. But just take a moment to do that using your own imagination; find a special, serene environment.

Perhaps a place where you've been before.

Or you can even create a place in your mind's eye, in your own imagination.

Some special place where you feel warm and safe, where you can feel the beauty and strength of the environment.

Imagine yourself as if you were really there in this place.

A wonderful atmosphere that feels comfortable, peaceful, and just using all of your senses, feel this environment around you; the beauty that you see.

The quiet and pleasant rhythmic sounds of the environment.

Feel the warmth on your skin.

Even the smells that may feel familiar to you. Imagine exploring your environment, noticing all of the details. This is your special place. And notice the feelings and impressions that you're beginning to experience. In exploring your surroundings, if there's anything you'd like to do to make it your special place or more comfortable, feel free to do so. Either a shelter or imagining the whole area with a golden light of protection and safety.

But just noticing how calm you feel, how much more peaceful.

You're creating kind of a sanctuary, that’s only yours.

You can come back and visit at will.

Every time they need to feel these feelings of increased safety or understanding and peace, you can come to explore yourself, or just to find calmness and to enjoy your special place. It's personal. But it can be a place where you come to find calmness, to get in touch with your feelings.

We're going to leave the place now by just imagining by focusing again and counting on your breathing.

This time, counting backwards from five towards one, slowly to yourself, counting, and on the count of one, in your own time, just leave the exercise and then we'll come back into the room.

On the count of one, bringing the sense of calmness and feeling more relaxed, along with you.

Adapted from Korn E, In Sheikh A (Ed.) 1986. Anthology of Imagery Techniques. American Imagery Institute, Department of Psychology. Marquette University, Milwaukee Wisconsin)

This taped mediation by Mary Jane Esplen was part of this published research project.

2. Future self

» View a text version of the future self guided imagery exercise

Focus on your breathing counting from one up towards 10, allowing each breath to become deeper and slower, allowing any tension to go from your body as you breathe outward.

Just breathing slowly and deeply from one up towards 10. Slowly and deeply, allowing your body to become more, more relaxed. Imagine a beautiful natural scene that you would like to be part of.

Perhaps near the water, or in the woods, or in the mountains whatever images arrive. And imagine a path, or a road on which you have been traveling in your image of serenity. Just a path, stretching out in front of you and farther than the eye can see. Imagine that this is your life's journey. Take a moment to use your sense, all your senses, and feel this place. The sounds around you that you hear, the beauty you see and feel, even the temperature. Take time to do that. Whatever comes to you with pleasure.

Now imagine there is a figure on the path ahead of you, walking where you have not walked, seeing what you have yet to see. Kind of a future self; wiser, more evolved, content, stronger, and at peace and of acceptance. Stronger in many ways, in comparison to how you feel now. But accepting of you. This future self is a kind of self you would like to be. That best self that’s your guide, who is leading you on ahead in life’s path.

Pause and observe everything you can about this person, or future self. How does she look? What are you noticing about her manner? What emotions does she elicit in you? What bond do you feel with her? How is she different from the self you are now, or how you see yourself now? How does the inner self of you feel about this future self? Imagine that you are that future self and you are looking back at yourself as you currently are. What do you see? As a future guide how do you feel about this present self? Do you want to help her? What do you want her to know? What important things must she do, or see, or understand before becoming this best future self? What are your current strengths? Do you see parts of yourself that are growing, evolving? Maybe moving towards your future self or guide? Pause and think about the self-wisdom your future self is giving you. Let the conscious part of your mind take note of this gift from the unconscious. If it is too much to absorb now ask your inner self, or even your unconscious to store it, just for now, but to give it to you at exactly at the right time. As your current self, say to yourself, “I will become you. I look forward to that. I can see that inner strengths and aspects of myself are there, and they're growing, becoming more apparent. And they're becoming more important to me.” As your future self say to yourself “I will always be inside you.”

If you will, leave part of yourself to stay on this path walking into the future, becoming more and more what you see yourself becoming. Aspects that you also identify with strength. And with what you've learned about yourself. Aspects also beautiful that exhibit, your uniqueness, your sense of being you, which are so much of value and part of you. Allow yourself to become more and more of what you wish to be on this path to your future self.

Let the scene fade from your imagination now, breathing again deeply, focusing on your breathing. Energizing breaths. Slowly opening your eyes again, taking note from the exercise. What seemed most important to you? What was most surprising? What seemed wise?

And feel free to come back to the exercise in your own mind by closing your eyes and repeating the exercise to visit your future self, to see where you are on the path and to let your future self guide you with the wisdom.

Adapted from Steinem (1992) Revolution From Within, Little, Brown and Company: Boston.

This taped mediation by Mary Jane Esplen was part of this published research project.

3. Self-Imaginal Massage

» View a text version of the self-imaginal massage guided imagery exercise

Let's begin the exercise, by focusing on your counting, and your breathing from one towards five breathing slowly and deeply, allowing your breathing to come out through your mouth and in through your nose, just counting silently to yourself from one up towards 5. Feeling more and more comfortable and relaxed.

For this exercise allow your mind to return to a time when you experienced feelings of love or compassion, either as a giver, or the receiver.

Just allow yourself to re-experience that memory as if it were happening to you right now. See what you saw. Try to imagine hearing at that time what you heard, and imagine feeling. Try to really feel what you felt at that time, and really be in the image. Let all of your senses savour this feeling of love and compassion.

Experience the feelings of love centering in the area of your heart, feeling your heart alive with compassionate and loving feelings. Now imagine and think about — just become conscious of your hands, focusing on your hands, becoming increasingly aware for the exercise, of your hands and put all your attention, move all your attention now to your hands. Take all of that loving, or that compassion, those rich and warm, beautiful feelings of compassion and love and feel them flowing if you can, from your heart, now into your hands.

Just imagine doing that now. Feel your hands filling with compassionate feelings. Even tingling and pulsating in your hands with feelings of love, acceptance and of caring. As you breathe, breathe into your hands, and feel the loving feelings intensify, even seeing if you can build the intensity of this feeling with each breath. Feel the feeling of warmth as you breathe even more feelings of compassion into your hands. Imagine your hands are tingling now. Even beginning to glow with an aura of loving kindness. Your hands are incredibly alive and vibrant. Just feel them. Focusing on your hands, just feel them. Now imagine that you're in a safe and comfortable room of your choice, where the lights are soft and low but you still can see around you. Imagine that you are naked and fully comfortable in the room, you're feeling completely safe. Taking the time you need to settle yourself, or do what you need to feel comfortable in this room, in this scene. If you feel comfortable imagine the feeling of warmth of these loving, caring hands as they move tenderly along your own body at your own pace. Covering, first of all, every inch of your face. Focusing on your face. And then moving freely, if you can, even imagining an oil infused with love and caring. Imagine just gently with all your senses, feeling the warmth of the caring hands. Perhaps the fragrance of the oil. And the sound of your breathing. And the sight of loving eyes and hands moving on your body.

In a sense, your hands are lovingly massaging those parts of your body that you like and parts of your body that have received positive, and compassionate feelings from you. Just imagine this if you can. And what the feeling is like for you. Just at your own pace and where you feel comfortable. As these parts of you are being massaged, try to imagine feeling some of the positive energy that they hold transferring into the loving and the massaging hands. The hands may even be glowing or feel even brighter now. And take as much time as you need to experience the healing nature, compassionate hands as they tenderly massage and caress parts of your body that may have been feeling, an area of shame, or where you have felt disappointment, or any negative feelings. Imagine that these parts or aspects of your body are being touched and handled with love, sensitivity, but a caring. Even imagining they melt into softness and can fully surrender and receive all the compassion, flowing into the area right now.

You can begin to feel your body coming more into balance as you soak up the compassion almost like a sponge does with water.

You are worthy of love and compassion. You deserve compassion, and just see how much love or compassion you can take in right now. It may also help to feel the radiant hands caressing your body and as you look into your own loving eyes, try to surrender the part of you that has the wisdom. A more true perception. But most importantly compassion. The part of you that accepts you. And loves you just the way you are. You can revisit the exercise, but try to spend at least 10 minutes or so caressing your own imaginal body with love and healing and being aware, perhaps writing about your feelings in response to the exercise. See how much of the feelings of self-acceptance and compassion, you're willing to bring back with you when you later open your eyes. You can revisit this exercise over time, and spend as much time as you like simply being with yourself. Being with yourself and the feelings that you have whatever they are.

Focus again on your breathing. If it helps counting from five back towards one. And on the count of one in your own time just come back into your room, and open your eyes on the count of one.

(Adapted from: Hutchinson, M.G. 1985. Transforming Body Image: Learning to Love the Body You Have. Freedom, CA: The Crossing Press).

This taped mediation by Mary Jane Esplen was part of this published research project.

This resources section is adapted from:

Restoring Body Image in Breast Cancer (ReBIC) Support Group- Treatment Manual; Authors- Mary Jane Esplen, PhD, Brenda Toner, PhD, Virginia Boquiren, PhD, Lianne Trachtenberg, PhD, Jiahui Wong, PhD.
Restoring Body Image after Cancer (ReBIC): A Group Therapy Intervention (in press) Esplen, MJ, Warner, E. , Boquiren, V. Wong, J. Toner, B. Psycho-oncology.
Feasibility and acceptability of i-Restoring Body Image after Cancer (i-ReBIC): A pilot trial for female cancer survivors

Trachtenberg, L., Wong, J., Rennie, H., McLeod, d., Leung, Y. Warner, E., Esplen, M. . Psycho-Oncology. 2020;1–8.https://doi.org/10.1002/pon.5288