“By the time they found the lump, I had been in recovery from my eating disorder for almost ten years. I thought I had left that part of my life behind, but then I realized it might have followed me into my cancer diagnosis. I was a single mother, juggling work, kids, and the exhaustion that never quite leaves you after you’ve spent years starving your body. Breast cancer felt like a second betrayal, coming from a body I had already spent half my life fighting.” – Marta*

According to the National Breast Cancer Foundation, about one in eight women¹ in the United States will be diagnosed with breast cancer in their lifetime, making it the most common cancer among women after skin cancer. At the same time, nearly one in seven women will experience an eating disorder by their 40s or 50s². What’s important to note, however, is that men and people of all gender identities can also develop breast cancer and eating disorders, as these conditions are not exclusive to women. Although stories like Marta’s are not unique, there currently exists a need for research and awareness on the unique challenges patients with breast cancer face that can predispose them to maladaptive coping mechanisms like disordered eating. However important for health, this crucial intersection remains overlooked, specifically when it comes to body image.

What is Body Image?

Body image includes the thoughts and feelings a person can have about their body³. 

Why Can Poor Body Image Develop in People with Breast Cancer?

Breast cancer treatments can evoke changes in body composition, shape, appetite, and more. Treatment response is highly variable, and some people may experience little to no changes, while others may experience drastic changes. How can cancer therapies evoke body changes? Here are some examples:

• Surgery

Surgical intervention⁴ is often the first choice of treatment for breast cancer. This may include a mastectomy⁵, in which one or both breasts is removed as a means of eliminating breast tissue and other surrounding tissues that may contain cancer cells. Aside from removal of the entire breast, surgery may include removing part of the affected breast(s), and this may result in scarring, asymmetry between breasts, and other changes that can be distressing for patients. 

• Chemotherapy 

Chemotherapy⁶ is another common intervention against breast cancer. However, because it does not differentiate between fast-growing cancer cells and other fast-growing cells, it can cause appearance changes, such as hair loss. Sarcopenia⁷, or a deterioration in muscle mass and strength, can also occur, and this can induce visible changes in body composition and fat distribution⁸, which can also be distressing.

• Hormonal Changes: Estrogen

About 2 in 3 breast cancers^{9, 10} require hormones, such as estrogen¹¹, to survive and grow. Medications may be prescribed to prevent estrogen function. Because estrogen is important for many organ systems, including skin, estrogen-targeting treatments may result in visual changes in skin elasticity and appearance. 

The aforementioned do not include all breast cancer treatments and all the ways they can invoke changes in appearance. Treatments are also often used in combination, and thus can evoke multiple modifications. Body changes can invoke changes in body image, and as such, special care should be taken to monitor changes in body image for patients with breast cancer. The table below shows the different components of body image³, as well as examples of what body image concerns/disturbances could look like in patients with breast cancer.

Table 1. The Different Factors of Body Image and Possible Manifestations in Breast Cancer Patients.

Note: For patients with breast cancer, none of these changes are your fault. They are normal responses to treatment, and don’t mean that you are doing anything wrong. Talking with your care team about how these changes feel, both physically and emotionally, is an important part of healing, even after treatment occurs, and long into survivorship.

Body Image in Patients with Breast Cancer

Body image disturbances represent critical yet insufficiently addressed¹² aspects of breast cancer care. Nearly half of women diagnosed with breast cancer report significant body image concerns, and body image concerns may predispose individuals to developing disordered eating and/or eating disorders¹³.

Eating Disorders, a Basic Overview

Eating disorders are mental health conditions characterized by severe disturbances in an individual’s eating habits. Disordered behaviors include restriction of food intake, binge-eating, and compensatory behaviors, including self-induced vomiting, overexercising, and other weight-control behaviors. Eating disorders include Bulimia Nervosa, characterized by episodes of overeating (binge-eating) and compensatory behaviors, and Anorexia Nervosa, with subtypes that include restriction and binging-and-purging. Other Specified Feeding or Eating Disorder (OSFED) includes disordered eating behaviors that warrant concern but do not meet criteria for one specific eating disorder. Of note, eating disorders also include Avoidant/Restrictive Food Intake Disorder (ARFID), which is characterized by severe fear and anxiety regarding food intake and its consequences, without the weight-control and body image component. The difference between an eating disorder and disordered eating lie in the impact that the behaviors and thoughts have on one’s life.

Note: You do not need to have a diagnosed eating disorder to be worthy of recovery and support. Struggles with food or body image are enough to warrant care.

Body Image Care as a Safety Net

Note: Talking with your care team about how these changes feel, both physically and emotionally, is an important part of healing, even after treatment occurs, and long into survivorship.

What Else Can Fuel Disordered Eating for People with Breast Cancer?

For people with breast cancer, with either a history of disordered eating or a predisposition to developing disordered eating patterns¹⁵, the process of being diagnosed and undergoing breast cancer treatment can be exceedingly and emotionally distressing. The relationship between emotions and eating disorders can be complex, and disordered eating may develop as a coping mechanism to manage the different changes that come with a diagnosis. 

Moreover, for those well into survivorship, the fear of remission can cause patients to focus on what they believe may reduce their risk of remission: food¹⁶. A 2022 study¹⁷ from the Journal of Eating Behaviors found that 70% of individuals diagnosed with breast cancer vowed to change their eating habits in some way as a result of their diagnosis. Although a healthier diet can be beneficial, almost 40% of these patients met clinical criteria for Orthorexia Nervosa (ON). ON refers to a pattern of disordered eating in which an unhealthy obsession occurs over “eating [only] healthy food.” Some may wonder how eating only healthy food can be harmful. It has been shown that an unhealthy relationship with food, even if you eat only healthy food,  can still lead to malnourishment and poor quality of life¹⁸.

Integrating Eating Disorder awareness into breast cancer care

With body changes being a risk factor for body image distress, individuals going through a breast cancer diagnosis deserve to have body image care incorporated into the management of their disease. This can include screenings¹⁹ for disordered eating or eating disorders (including the SCOFF Questionnaire or EAT-26), check-ins with a provider about how they feel physically or emotionally, and targeted psychotherapy or support groups for patients with breast cancer. 

For providers and caretakers, taking note of changes in eating or eating concerns can be crucial²⁰ for early detection of an eating disorder. Integrating this awareness into breast cancer care is an important step towards a more comprehensive approach that goes beyond the tumor and takes care of the patient as a whole.

Understanding what body image is and how body image disturbances can manifest into disordered eating is paramount to the treatment of the whole person, thus being essential to the treatment of breast cancer and many other cancers. In turn, this can improve treatment plans and help patients like Marta, where treatment of the eating disorder and breast cancer are necessary to improve overall quality of life. Marta’s case is one of many, and as such, more care needs to be taken to address body image in breast cancer treatment. 

For providers, caretakers, and support people alike, let the diagnosis become an invitation: to design and implement care that goes beyond the tumor to care of the whole human being. Together, we can build a team that addresses people with breast cancer as a whole, and rebuild trust in one’s body and its capacity for healing, recovery, and growth. 

*Note: Pseudonym used to preserve confidentiality.

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Ashley Saldana

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