At an early stage, breast cancer treatment is based on surgery, radiotherapy and systemic therapy. Radical surgery remains necessary in certain circumstances.

As the breast is a symbolic organ related to femininity, physical attractiveness and motherhood, breast amputation could be of a major impact on body image, self-esteem and sexual functioning [1]. Thus, breast cancer patients would not only face their disease and the physical adverse events of treatment, but also several mental challenges.

In this regard, self-esteem is the attitude towards the self. It could be defined as the level of love and respect that someone hold for himself [2, 3]. Self-esteem reflects the acceptance and satisfaction with oneself [4]. The oncologist tends to ignore the psychological side of cancer patients by focusing on treatment and therapeutic efficacy.

Herein, we aimed to elucidate the impact of mastectomy on the self-esteem of patients with early breast cancer treated at the medical oncology’s department of Habib Bourguiba Hospital in Sfax, Tunisia.

This cross-sectional study investigated self-esteem in women after mastectomy for early breast cancer. The subjects were recruited at our medical oncology’s department of Habib Bourguiba Hospital in Sfax, Tunisia. Patients were treated by modified radical mastectomy without reconstruction. At least 3 months had elapsed since their surgery. We excluded women with metastatic cancer or active disease and those undergoing bilateral mastectomy or breast reconstruction. Informed consent has been appropriately obtained.

We used our own questionnaire to determine data about age, sex, education, professional activity, marital status, menopausal status and family emotional support. Moreover, background information, including operated side and use of neo adjuvant and adjuvant therapy was also evaluated for each subject. Data was collected by mobile phone or face to face consultation. Women were also asked about their partner’s attitude towards breast reconstruction.

The Rosenberg scale was used to measure the overall level of self-esteem of all respondents [5]. The questionnaire consists of 10 items rated on a four-point Likert scale from “strongly agree” to “strongly disagree” (Online Resource 1). The score can be calculated by totalling the 10 items after reverse-scoring for the negatively stated items. The scale is divided into 5 ranges: very low (< 25 points), low (25 – 30), normal (31 – 34), high (35 – 39) and very high self-esteem (> 39 points).

Statistical analyses were conducted using IBM SPSS Statistics 20.0. Variables were checked by the Kolmogorov–Smirnov test for distribution regularity. We calculated counts (n) and proportions (%) of the qualitative variables and means (m) and standard deviations (SD) for the quantitative variables. We analyzed factors associated with self-esteem using the X2 test. Testing probability of p < 0, 05 was considered significant.

The study was conducted between November 2021 and March 2022. A total of 58 patients with early breast cancer were included in the sample. Mean age was 52, 53 years (SD ±10, 18). Clinical characteristics are summarized in table 1. Forty-four patients (75, 9 %) were diagnosed with breast cancer in the last 5 years. Left sided mastectomy was performed in 51, 7 % of patients. Time between the surgery and the date of the questionnaire ranged from 8 to 154 months, with a median of 26, 5 months. Among married women, none of their partners urged them to undergo breast reconstruction.

According to Rosenberg scale, lower self-esteem was observed in 93, 1 % of patients (very low in 29, 3 % and low in 63, 8 %) (Figure 1). Median score was 28 (ranged from 16 to 40).

Figure 1:  Self-esteem levels in our study.

We analyzed risk factors associated with a lower self-esteem (Rosenberg score ≤ 30) (table 2). Married women were at a higher risk of low self-esteem levels (97, 9 % vs 70 %, p = 0,014). No statistically significant difference in the other subgroups was observed (working status (p = 0, 57), level of income (p = 1), emotional family support (p = 1), endocrine therapy (p = 0, 24) and time between diagnosis and the questionnaire (p = 1)).

Table 1: Clinical characteristics.

Table 2: Risk factors associated with lower self-esteem.

Self-esteem is considered as a major aspect of mental health and it is associated with recovery after severe illness [6]. Consequently, it should be an important focus in mental health promotion. Our study highlighted the negative impact of mastectomy on self-esteem levels in patients with early breast cancer.

In a Spanish study including women with early breast cancer undergoing surgery, Rosenberg scores were < 30 in 73,9 % of patients (low self-esteem < 26 in 35 % and medium self-esteem (26-29) in 38,9 %) [7]. Higher self-esteem levels were reported in women who were working (p = 0,006), whereas receiving endocrine therapy was significantly associated with poor self-esteem probably due to the adverse events of this treatment (p = 0, 02) [7]. In our study, we found higher rates of low self-esteem levels (Rosenberg score ≤ 30 in 93, 1 % of patients). This could be explained by the heterogeneity of the type of the surgery in the Spanish study.

In their sample including 37 women disabled due to mastectomy, Cieslak et Golusinski concluded that the higher the level of acceptance, the higher the self-esteem [8]. Coping with disability and self-esteem did not differ according to time since diagnosis. These results were consistent with our findings as self-esteem was not significantly associated with time since diagnosis (p = 0, 97).

[9] Reported a significant reduction in self-esteem for patients undergoing breast amputation compared to the control group (median Rosenberg score = 27 vs 30; p < 0, 0001) [9]. Among women treated with mastectomy, their partners urged them to undergo breast reconstruction in 15, 9 % cases. In our study, median Rosenberg score was 28 (similar to the literature). All the partners of our patients were indifferent regarding breast reconstruction. This may be explained by the low and middle income of our patients compared to the high costs of reconstruction surgeries.

In another study including 13 patients with breast cancer, interviewed women manifested lower self-esteem following mastectomy which persisted many years even after undergoing breast reconstruction [2]. Immediate reconstruction was associated with higher self-esteem and better quality of life compared with delayed surgery [10]. Conservative surgery improved self-esteem and psychological well-being compared to radical surgery [10].

Alvarez-Pardo et al reported that women without partner manifested better self-esteem following breast surgery compared to those having a partner (median Rosenberg score 36 vs 35,28) but the p value was not significant (p = 0,374) [11]. In our study, married women were at a higher risk of low self-esteem levels (p = 0,014). In fact, in our culture, there may be traditional gender roles and expectations that place a heavy burden on women to fulfill domestic tasks and caregiving responsibilities. These expectations can add to the pressures faced by married women. Besides, mastectomy can have an impact on a woman's sense of femininity and sexuality. Married women may have concerns about how their partners will perceive them after surgery, which can contribute to decreased self-esteem.

Several studies demonstrated that mastectomy was not only responsible of a diminished self-esteem, but also strongly associated with a lower body image and quality of life, a sexual dysfunction, an emotional instability and a loss of attractiveness and sexuality inside the couple leading to depression and anxiety [12, 9, 3, and 9]. Thus, the loss of a breast due to mastectomy will be perceived by many individuals as a serious blow to a woman’s identity and sense of self [13]. The existing literature emphasizes the female breast as a symbol of femininity and womanliness. Women characterize the loss of a breast as deprivation of womanhood or identity [14, 15].

Study Limitations

The findings of this study have to be seen in light of some limitations. The first is the small sample size and the heterogeneity among subgroups. Our results must therefore be interpreted with caution. Secondly, our study only examined the impact of mastectomy on self-esteem; thereby providing a limited understanding of its broader effects on psychological well-being.

Clinical Implications

Clinicians should be aware of the negative impact of mastectomy on the mental health of breast cancer patients. Along with family members, physicians should encourage women to face these challenges in order to maintain good quality of life and higher self-esteem, thus, preventing them from psychological disorders [2]. Other interventions such as physical activities, group therapies and beauty treatments demonstrated their effectiveness in enhancing self-esteem and body image of breast cancer patients [16-18].

Neo adjuvant chemotherapy is another option that may help down staging the tumor which can increase the chance of breast conservation [19]. Oncoplastic surgery became the standard of care in the management of breast cancer [20]. Thus, clinicians should minimize recourse to mastectomy and promote oncoplastic techniques in order to reduce the negative impact of radical surgery on mental health.

Patients need medical, social, and psychological support during and after completion of treatment for breast cancer. The health care team should use an integrative approach in order to satisfy all patient’s needs. A multidisciplinary team consisting of a doctor, nurse, psychiatrist, psychologist, social services expert, dietician, physical therapist, a pharmacist, and clergyman or other spiritual advisor is of a main importance [21, 22].

Breast amputation is a traumatic event experienced by women. Our study underlined the negative impact of mastectomy on the self-esteem of patients with early breast cancer. Married women were at a higher risk of low self-esteem levels.

Awareness of these psychological effects may help clinicians to recognize most vulnerable women in order to provide them with the necessary support. Adoption of less mutilating surgical techniques need to be promoted in clinical practice. Patients should be offered the best surgical procedure in terms of oncological and cosmetic outcome.

Online resource. 1 Rosenberg self-esteem scale.

1. Sukartini T & Permata Sari Y. Women with breast cancer living with one breast after a mastectomy. Central European Journal of Nursing and Midwifery, 2021; 12: 366?375.
2. Berterö CM. Affected self-respect and self-value?: The impact of breast cancer treatment on self-esteem and QoL: AFFECTED SELF-RESPECT AND SELF-VALUE. Psycho-Oncology, 2002; 11:356?364.
3. Morales-Sánchez L, Luque-Ribelles V, Gil-Olarte P, Ruiz-González P & Guil R. Enhancing Self-Esteem and Body Image of Breast Cancer Women through Interventions?: A Systematic Review. International Journal of Environmental Research and Public Health, 2021; 18: 1640.
4. Niveau N, New B & Beaudoin M. How Should Self-Esteem Be Considered in Cancer Patients? Frontiers in Psychology, 2021; 12: 763900.
5. Rosenberg M. Society and the adolescent self-image. Princeton University Press. 1965.
6. Mann M, Hosman C, Schaalma H & Vries N. Self-esteem in a broad-spectrum approach for mental Health promotion. Health education research, 2004; 19: 357?372.
7. Cobo-Cuenca AI, Martín-Espinosa NM, Rodríguez-Borrego MA & Carmona-Torres JM. Determinants of satisfaction with life and self-esteem in women with breast cancer. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 2019; 28: 379?387.
8. Cie?lak K & Golusi?ski W. Coping with loss of ability vs. Emotional control and self-esteem in women after mastectomy. Reports of Practical Oncology and Radiotherapy, 2018; 23: 168?174.
9. Tarkowska M, G?owacka-Mrotek I, Nowikiewicz T, Monastyrska-Waszak E, Gastecka A, Goch A & Zegarski W. Sexual functioning and self-esteem in women after mastectomy – a single-centre, non-randomised, cross-sectional study. Contemporary Oncology, 2020; 24: 106?111.
10. Markopoulos C, Tsaroucha A, Kouskos E, Mantas D, Antonopoulou Z & Karvelis S. Impact of Breast Cancer Surgery on the Self-Esteem and Sexual Life of Female Patients. Journal of International Medical Research, 2009; 37: 182?188.
11. Álvarez-Pardo S, De Paz JA, Montserrat Romero-Pérez E, Portilla-Cueto KM, Horta-Gim MA, González-Bernal JJ, Fernández-Solana J, Mielgo-Ayuso J, García-Valverde A & González-Santos J. Factors Associated with Body Image and Self-Esteem in Mastectomized Breast Cancer Survivors. International Journal of Environmental Research and Public Health, 2023; 20: 5154.
12. Koçan S & Gürsoy A. Body Image of Women with Breast Cancer after Mastectomy?: A Qualitative Research. The Journal of Breast Health, 2016; 12: 145?150.
13. Fallbjörk U, Salander P & Rasmussen BH. From « no big deal » to « losing oneself »?: Different meanings of mastectomy. Cancer Nursing, 2012; 35: E41-48.
14. Piot-Ziegler C, Sassi ML, Raffoul W & Delaloye JF. Mastectomy, body deconstruction, and impact on identity?: A qualitative study. British Journal of Health Psychology, 2010; 15: 479?510.
15. Yurek D, Farrar W & Andersen BL. Breast cancer surgery?: Comparing surgical groups and determining individual differences in postoperative sexuality and body change stress. Journal of Consulting and Clinical Psychology, 2000; 68: 697?709.
16. Awick EA, Phillips SM, Lloyd GR & McAuley E. Physical activity, self-efficacy and self-esteem in breast cancer survivors?: A panel model. Psycho-Oncology, 2017; 26: 1625?1631.
17. Landry S, Chasles G, Pointreau Y, Bourgeois H & Boyas S. Influence of an Adapted Physical Activity Program on Self-Esteem and Quality of Life of Breast Cancer Patients after Mastectomy. Oncology, 2018; 95: 188?191.
18. Quintard B & Lakdja F. Assessing the effect of beauty treatments on psychological distress, body image, and coping?: A longitudinal study of patients undergoing surgical procedures for breast cancer. Psycho-Oncology, 2008; 17: 1032?1038.
19. Fisher B, Brown A, Mamounas E, Wieand S, Robidoux A, Margolese RG, Cruz AB, Fisher ER, Wickerham DL, Wolmark N, DeCillis A, Hoehn JL, Lees AW & Dimitrov NV. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer?: Findings from National Surgical Adjuvant Breast and Bowel Project B-18. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 1997; 15: 2483?2493.
20. Gilmour A, Cutress R, Gandhi A, Harcourt D, Little K, Mansell J, Murphy J, Pennery E, Tillett R, Vidya R & Martin L. Oncoplastic breast surgery?: A guide to good practice. European Journal of Surgical Oncology: The Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, 2021; 47: 2272?2285.
21. Doumit MAA, Huijer HAS, Kelley JH, El Saghir N & Nassar N. Coping with breast cancer?: A phenomenological study. Cancer Nursing, 2010; 33: E33-39.
22. Remmers H, Holtgräwe M & Pinkert C. Stress and nursing care needs of women with breast cancer during primary treatment?: A qualitative study. European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society, 2010; 14: 11?16.