Discussion
This nationwide population-based study showed that the body image of
adolescent survivors of childhood cancer was overall comparable to that
of their healthy siblings. Female survivors, survivors treated with
haematopoietic stem cell transplantation, and those with a higher burden
of chronic health conditions had a more negative body image. This was
particularly pronounced for survivors suffering from musculoskeletal or
endocrine conditions.
This is one of few population-based studies investigating the body image
of adolescent survivors of childhood cancer. Body image is a complex
psychological construct including body-related self-perceptions and
self-attitudes such as beliefs, feelings, and
behaviours.19 Although
cancer and treatment-related changes in appearance and the high
prevalence of physical late consequences after successful treatment
would be expected to adversely interfere with survivors’ body
image,4 our study showed
that the body image of adolescent survivors was overall comparable to
that of their healthy siblings. This is in line with a study from the
Netherlands including adult
survivors9 and a
previous systematic review including also studies with patients on
active treatment.19Evidence from other studies including adolescent long-term childhood
cancer survivors is limited by lack of population-based sampling
approaches and restrictions to certain cancer
types.35-37
Similar to a recent study from Sweden including adult childhood cancer
survivors20 and
findings in healthy adolescents in the general population of
Switzerland,28 we found
that female survivors were more likely to have a more negative body
image than male survivors. This confirms the extensive literature on sex
differences in body image indicating that females are more likely to
negatively self-evaluate their appearance and report higher levels of
body image dissatisfaction than
men.34 Societal
pressures and attractive body image expectations may be particularly
pronounced in Western
cultures.14 Our
findings indicated that survivors from French or Italian-speaking
Switzerland were more likely to report a negative body image than
survivors from German-speaking parts. However, we are not aware of other
studies reporting on within country differences in body image and
hypothesize that this may be explained by differential reporting
behaviour rather than underlying differences in body image.
We further found survivors treated with HSCT were more likely to have a
negative body image. HSCT is often used for high-risk disease or as
second-line
treatment.38 Physical
side effects and toxicity may occur at various stages of HSCT treatment
from intensive pre-transplantation therapy, conditioning regimens,
chronic immunosuppression, and acute or chronic graft-versus-host
disease (GvHD).39Transplanted survivors may also experience unique late consequences such
as delayed immune reconstitution leading to recurrent infections and
chronic dermatologic conditions as a result of chronic GvHD of the skin
that may adversely interfere with their body image in the
long-term.39 However,
our study included only 30 survivors treated with HSCT and more research
is needed to elucidate the underlying mechanisms.
Chronic health conditions were an important determinant of a more
negative body image in our study. Even though we included also mild
chronic conditions, we found that the more conditions adolescent
survivors experienced, the higher was their risk to report a negative
body image. This was particularly pronounced for survivors suffering
from musculoskeletal or endocrine conditions. Musculoskeletal conditions
such as prolonged pain in bones or joints, scoliosis, or reduced
flexibility of joints are visible disabilities and likely to interfere
with survivors’ everyday life compared to non-visible conditions such as
cardiovascular or pulmonary diseases. Indeed, qualitative research
indicated that childhood cancer survivors felt negatively about their
bodies because of the visible effects of the treatment such as hair
loss, weight gain, scarring, or
amputations.9,15-18The most common endocrine conditions in our study included growth
hormone deficiency that may cause short stature, and hypo- and
hyperthyroidism leading to hormonal
imbalance.40 Such
conditions may directly interfere with survivors’ body image and
psycho-sexual development particularly during adolescence. Indeed, we
found a strong association between growth hormone deficiency and a more
negative body image. Treatment with recombinant human growth hormones
significantly improves height in children with growth hormone
deficiency, however, affected children may still not achieve their
genetic potential.40Endocrine problems and hormonal imbalances may further interfere with
pubertal development. Reduced breast development may to some extent also
explain the more negative body image of female survivors compared to
male survivors. Collectively, our findings highlight that health care
professionals should be aware of the risk of body image concerns in
survivors with a high burden of chronic health conditions and therefore
address this problem during follow-up
care.41 Additional
support and counselling by an interdisciplinary team involving
psychologists may help affected survivors to reduce body image concerns.
This is of particular importance as an adverse body image has been
previously shown to be associated with psychological
distress14 and sexual
dysfunction13 in
childhood cancer survivors. In turn, this may affect survivors’
involvement in intimate relationship and family planning and their
quality of life in the
long-term.9 While
somatic health conditions after childhood cancer are usually well cared
for during long-term follow-up care, this may be less standardized for
aspects related to mental health such as body image
concerns.42 In the
literature, most body image interventions such as cognitive behavioural
therapy, education-based intervention, strength training, and physical
exercise have been implemented among survivors of breast cancer and it
remains unclear whether such approaches would be efficacious in the
childhood cancer survivor
population.14 A
promising approach is the recently established Fex-Can Childhood project
that includes an interventional approach to advance knowledge in the
areas of sexual function and fertility-related distress after childhood
cancer including body image as a secondary
outcome.43 If proven
efficacious and successfully implemented in survivorship care, such an
approach could be particularly beneficial for adolescent survivors with
body image concerns and may contribute to mitigate adverse long-term
consequences.
A limitation of our study is the relatively small number of siblings.
Sibling comparisons are valuable as they offer a possibility to control
for possible confounders such as socio-economic
background31 and we
further maximized comparability by standardizing for age at study and
sex. However, our study may have lacked the statistical power to detect
small differences between groups. Another limitation may be reporting
bias due to social
desirability.44Survivors may have reported more favourable outcomes and our study
therefore may have underestimated the implications of the cancer
diagnosis and related chronic health conditions on survivors’ body
image. However, this may to some extent also apply to sibling
comparisons. Finally, agreement with the statement I would like to
change a few things regarding my body should not necessarily be
interpreted as an adverse outcome but should be seen in light of
personal choices such as the wish to build up muscles for example. A
strength of our study is the nationwide and population-based sampling
approach and the high response rate that supports the representativeness
of our study population. We have previously shown that non-response bias
may only play a minor role in Swiss childhood cancer survivor
studies.45 In our
study, we cover all childhood cancer types and treatment periods from
1976 to 2010. Another strength refers to the use of high quality
clinical information based on medical records from the SCCR and the
assessment of chronic health conditions based on standardized questions
used in other childhood cancer survivor
studies.24,25
In conclusion, it is encouraging that the body image of adolescent
childhood cancer survivors was comparable to healthy siblings. However,
a subgroup of survivors with a high burden of chronic health conditions
might develop a negative body image during adolescence. These survivors
could benefit if health care professionals addressed such concerns in a
standardized way during follow-up care and offered psycho-social
support.