DOCTYPE = ARTICLE
Changes in Body Image Experienced
by Adolescents With Cancer
Sandie S. Larouche, RN BSc, MSc(A)
Lily Chin-Peuckert, RN BSc, MSc, MSc(A)
Cancer and its treatments affect adolescents’ body
image. However, it is not known what factors impinge on
adolescents’ perception of their body image. This multiple case study explored how 5 adolescents with cancer
perceived their body image and the impact of this perception on their daily life. Adolescents described their
body image as “I don’t look normal,” a theme that comprised 2 dimensions: “I look ugly” and “I look sick.”
For the adolescent with cancer, these 2 dimensions
evoked feelings of being vulnerably exposed: “People
look at me.” Consequently, adolescents adopted a new
set of coping strategies to help them manage their physical appearance and social interactions: “avoiding,”
“maintaining normality,” “testing the waters,” and
“peer-shield” themes. Although the adolescents perceived their body image as altered, coping mechanisms
enabled adolescents to think of themselves as normal
and re-establish their social lives. The results of this
small study suggest 2 potential nursing approaches to
facilitate adolescents’ adaptation to their new body
image.
Key words: adolescent, body image, cancer, coping,
perception
C
ancer and the associated treatments often generate
harsh side effects that can significantly alter the
patient’s physical appearance. Given the importance of
© 2006 by Association of Pediatric Oncology Nurses
DOI: 10.1177/1043454206289756
200
body image during adolescence, such physical changes
can increase suffering and distress in the adolescent
with cancer (Thompson, 1990) and lead to maladaptation (Trask et al., 2003).
Few studies have focused on the holistic and meaningful characteristics of real-life events from the perspective of the adolescent with cancer. The existing
literature on adolescents with cancer is derived mainly
from quantitative studies that are broad in scope
(Whyte & Smith, 1997). However, studies on adolescents with cancer using both qualitative and quantitative methodologies suggest that semistructured
interviews may reveal a more realistic representation
of their lived experiences (Aasland & Diseth, 1999;
Puukko, Sammallahti, Siimes, & Aalberg, 1997). The
purpose of this small qualitative study was to explore
adolescents’ perspectives of the impact of physical
changes when confronted with cancer treatment.
Knowledge of how these changes are perceived by
adolescents will help identify the issues that these
patients face and, subsequently, enable health care professionals to consider interventions to decrease the
associated anguish.
Sandie S. Larouche, RN BSc, MSc(A), is a clinical nurse specialist with the
Department of Nursing, Sir Mortimer B. Davis-Jewish General Hospital,
Montreal, Quebec, Canada. Lily Chin-Peuckert, RN BSc, MSc, MSc(A), is
with the Department of Nursing, Montreal Children’s Hospital/McGill
University Health Center, Montreal, Canada. Address for correspondence:
Sandie Larouche, Sir Mortimer B. Davis-Jewish General Hospital,
Department of Nursing, 3755 Côte Ste-Catherine Road, Montreal, Quebec,
Canada H3T 1E2; e-mail: [email protected].
Journal of Pediatric Oncology Nursing, Vol 23, No 4 (July-August), 2006: pp 200-209
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
Changes in Body Image
Literature Review
Adolescents and Body Image
Adolescents face a complex transition from childhood to adulthood that involves the development of
their own identity (Erickson, 1963). An adolescent’s
body image is a central and intricate aspect of identity development (Eiser, 1996). Schilder (1950)
defined body image as “the picture of our body which
we form in our mind . . . the way in which our body
appears to ourselves” (p. 11). Body changes and egocentrism evoked during adolescence lead to a preoccupation with the way adolescents look and compare
themselves with others.
Adolescents and Cancer
Although the transition from childhood to adulthood is normally a challenging period for teenagers,
some carry the extra burden of illness. Approximately
2 of 10 000 teenagers aged 15 to 19 years are diagnosed with cancer each year in North America (Stiller,
2002). With the advancement of diagnostic tools and
the development of new treatment protocols, the number of adolescents surviving cancer is increasing. These
protocols use many different modes of treatments (ie,
surgery, radiotherapy, chemotherapy, immune therapy,
and hormone therapy), most of which are not without
side effects. Side effects range from nausea, vomiting,
and fatigue to more physical changes such as alopecia,
acne, weight changes, or even amputations.
The body-altering side effects of cancer treatments
are reported by adolescents to be one of the worst
aspects of the disease (Enksar, Carlsson, Golsater, &
Hamrin, 1997). Several authors have suggested that
changes in appearance as a result of cancer treatment
can lead to alterations of body image (Fritz & Williams,
1988; Lansky, List, Ritter-Sterr, & Hart, 1993;
Wasserman, Thompson, Wilimas, & Fairclough, 1987).
Adolescents’ level of self-consciousness can be
affected to the point that they withdraw socially (List,
Ritter-Sterr, & Lansky, 1991) and have fewer friends as
compared with their peers (Pendley, Dalhquist, &
Dreyer, 1997; Spirito et al., 1990; Vannatta, Gartsein,
& Noll, 1998; Vannatta, Zeller, Noll, & Koontz, 1998).
Qualitative studies involving adolescents with cancer have addressed wider issues such as the perceived
meaning and coping with cancer (Enksar et al., 1997;
Glasson, 1995; Hinds & Martin, 1988; Weekes &
Kagan, 1994; Weekes & Savedra, 1988; Woodgate,
1999) and have not focused on more specific issues
such as body image. The need for such studies is exemplified by the findings of Palmer et al. (2000) that coping with physical changes is an important issue for
adolescents with cancer. Similarly, Hedstrom, Haglund,
Skolin, and Von Essen (2003) found physical changes
to be distressing events for children with cancer of all
ages. Although both these studies identify changes in
appearance as a major concern for children and adolescents, the specific nature of this concern was not
explored in greater detail.
Previous studies on how pediatric cancer patients
perceive their appearance have included children of
all ages (Varni, Katz, Colegrove, & Dolgin, 1995)
rather than separating them into different age groups.
According to Dashiff (2001), ignoring the unique
developmental stage of adolescents may significantly
compromise the integrity of the study. Eiser (1996)
contended that adolescents’ perceptions may be very
different than those of younger children and suggested
that adolescents should be studied independently to
fully grasp their particular experiences. Dashiff (2001)
further suggested that studies involving adolescents
should consider the different developmental groups
within this population.
A major limitation to evaluating the effects of cancer and the associated treatment on the body image of
adolescents has been study methodology. Puukko et al.
(1997) evaluated the body image of leukemia survivors
by questionnaire and interview. The analysis
of their quantitative data (questionnaire) suggested that
adolescents have a normal body image, whereas analysis of the qualitative data (interview) showed that a
large number of these same adolescents had an
impaired body image (Puukko et al., 1997). This discrepancy may be explained by the ability of qualitative
studies to better capture the essence of the adolescent’s
cancer experience because it is gathered from the adolescent’s perspective (Woodgate, 2000). Eiser, Hill,
and Vance (2000) further argued that interviews with
children can detect problems that are not measured in
a questionnaire. Current evidence indicates that cancer
and its treatment affect the body image of adolescents.
However, it is not known to what extent cancer affects
body image, nor is it understood what factors impinge
on the adolescent’s perception of body image.
Journal of Pediatric Oncology Nursing 23(4);
2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
201
Larouche and Chin-Peuckert
Methods
Table 1. Demographics and Characteristics of Interviewed
Adolescents (N = 5)
Purpose
Adolescent
Little is known about how adolescents perceive their
body image while undergoing cancer treatment or how
they regain entry into their social milieu. The aim of
this study is to explore adolescents’ perceptions of their
body image when faced with cancer and its treatments
and the impact of this perceived body image on their
everyday life.
Design
Data Collection
A multiple case study design using semistructured
interviews guided this qualitative study. The aim of
this method was to retain the holistic and meaningful
characteristics of real-life events (Yin, 2002).
The adolescents were interviewed in a private room
during their regular appointments in the oncology
clinic or during a hospital admission. Each adolescent
was interviewed twice for a total of 10 interviews.
Observations related to the adolescents’ overall physical appearance were recorded and were used to validate the interpretation of the verbal interview data.
All the interviews were conducted in the absence of
the parents to ensure that the adolescents felt free to
express their thoughts and feelings. The semistructured interviews were audiotaped and lasted between
20 and 60 minutes. All interviews were carried out by
the same investigator. Adolescents were questioned
about the various different side effects (visible or not)
they were experiencing and how the side effects
affected their body. They were also asked how they
perceived these changes affecting their body image
and to identify how the changes affected their daily
lives. Data were collected from January to April 2004.
Ethical Considerations
The study was approved by the institution’s
Research Ethics Board. Participation in the study was
voluntary. Parents and adolescents gave informed
written consent.
Sample
On the days when the principal investigator was on
site, nurses in the hematology/oncology clinic identified potential participants from the appointment list.
Inclusion criteria were that participants should be
between 12 and 18 years of age, should be receiving
active cancer treatment at a university-based tertiary
pediatric hospital, and should speak English or French.
In total, 6 adolescents were identified and were
first approached by their primary nurse, who briefly
explained the study. Five adolescents and their guardians
agreed to meet with the investigator and, after a
detailed description of the study, gave written consent
to participate. One adolescent, who experienced extensive physical changes at the time of recruitment, was
reluctant to discuss her physical condition and refused
to participate. The final sample comprised 3 males and
2 females. They ranged in age from 14 to 17 years
(Table 1). These adolescents were diagnosed with a
malignancy within the past 3 to 12 months.
202
Gender
Age, Y
Diagnosis
1
M
14
Rhabdomyosarcoma
2
M
17
Hodgkin’s lymphoma
3
F
17
Leukemia
4
M
15
Osteosarcoma
5
F
15
Ewing’s sarcoma
NOTE: M = male; F = female.
Data Analysis
Data analysis was performed throughout the data collection period. Interviews were transcribed verbatim.
Detailed field notes describing the adolescent’s carriage
appearance and nonverbal behaviors were recorded
within 7 days following data collection. Line by line
coding of the transcripts was performed to categorize
data into themes. Common themes that seized the meaning of the adolescent’s words were grouped together to
reveal the lived experience of the adolescent as well as
to validate the analysis of the findings (Strauss &
Corbin, 1998).
Journal of Pediatric Oncology Nursing 23(4); 2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
Changes in Body Image
Reliability and Validity
Perception of Body Image
Confirmation of the data was performed with the
adolescents throughout the interviews. During the second interview, interpretations were validated once again
to ensure an understanding of the adolescents’ perceptions. To ensure interrater reliability, the transcriptions
of the tapes and the categorization of the themes were
reviewed and analyzed by 2 nurse-researchers not affiliated with the pediatric hematology/oncology unit. A
summary of the overall findings was presented to the
hematology/oncology multidisciplinary team to ensure
that a valid interpretation of the data was made.
“I Don’t Look Normal”
Findings
This study explored the effect of cancer and cancer
treatment on adolescents’ perception of their body
image. Participants varied in age, diagnosis, time of
onset of disease, type of treatment, and degree of physical changes experienced. One participant did not elaborate much on his body image simply because he was
in the early phases of treatment and had not, at the time
of the interviews, experienced major physical changes.
Despite these differences, all 5 adolescents shared
many commonalities, such as being conscientious of
their physical appearance, being up to date with current fashion trends, having strong ties with their peers,
and having good support from family members. We
believe that both the differences and similarities of the
participants contributed to the results of the study. On
review and analysis of all the interviews, the overriding
theme that emerged was that adolescents perceived
their body image as different as expressed by, “I don’t
look normal.” The adolescents perceived that the physical changes they were experiencing made them look
unattractive (“I look ugly” and “I look sick”). These
thoughts aroused feelings of vulnerability (“people
look at me”) and had a large impact on the adolescents’
daily lives. However, adolescents in the study found
distinct ways to handle their body changes and control
the daily negative feelings of being noticed. The
themes characterizing these new behaviors were
“avoiding social situations,” “maintaining normality,”
“peer-shield,” and “testing the waters.” This new set of
coping behaviors enabled the adolescents to think of
themselves as normal and facilitated their adaptation
and reintegration into the social arena.
The main theme, “I don’t look normal,” was recurrent throughout the interviews. Adolescents reported
having noticeable physical changes that modified the
way they perceived their body image; they found that
they looked different than other adolescents, at times,
even abnormal or strange. This theme was clearly
articulated in statements like, “I’m not like the rest of
the people.” Adolescents attributed their body image
perceptions as not looking normal to different physical factors such as hair loss, presence of an implanted
subcutaneous central venous catheter (CVC), scars,
and pale skin complexion.
Hair loss and the presence of the CVC were cited
as the 2 major factors responsible for altering their
body image. Four participants described hair loss as
being the greatest physical challenge for them to
overcome while being treated for cancer. When asked
to describe what they did not like about losing their
hair, 1 adolescent stated, “Losing your hair it changes
your general look, your face, the whole person, the
image you display.” 1 participant when comparing
her perceived change in body image to that of her
friends stated, “I lost all my hair, but all my friends,
they all have hair.” The adolescents referred not only
to the hair loss on their heads but also to hair loss on
other parts of their bodies. For instance, 1 adolescent
reported, “The eyebrows, the eyelashes are not looking
normal. . . . Even if I have my hat, I have no hair on my
face and it’s like I have a face all white and scratched
everywhere.” As for the CVC, the adolescents perceived their bodies as “weird” when talking about the
obvious appearance of the implant and resultant scar.
One adolescent stated, “It looks awkward. It’s unusual.
It’s not what people are used to seeing.”
For the adolescents in the study, the theme “I don’t
look normal” carried 2 different but not mutually
exclusive meanings: “I look ugly” and “I look sick.”
“I look ugly.” The first dimension, “I look ugly,”
was reported by 3 adolescents. A 15-year-old participant with extensive scarring following surgery who
was undergoing chemotherapy described his feelings
about his appearance:
Look at me, I’m not nice looking at all, I have no
hair, I have a big scar, a big thing here [pointing
Journal of Pediatric Oncology Nursing 23(4);
2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
203
Larouche and Chin-Peuckert
to CVC]. . . . I have dry skin. . . . I have small dry
pieces of skin everywhere on the face and on my
nose. . . . This does not make a nice looking face.
Although many factors were at the root of this adolescent’s body changes, they all carried the same
meaning: “I look ugly.”
The degree of perceived ugliness, however, differed among the adolescents and ranged from being
less attractive to being totally ugly. One 15-year-old
expressed a strong reaction to his body perception,
“I find myself hideous without hair,” whereas other
participants used more positive descriptions to portray
the way they saw their bodies. As one 17-year-old girl
stated, “I find myself less pretty.”
“I look sick.” The second dimension emerged from
the adolescents’ perceptions of “looking sick.” All 5
participants described that looking at themselves in the
mirror and seeing all the physical changes constantly
reminded them of cancer and/or that they are sick. One
17-year-old identified the look of her bald head as carrying the look of illness: “when you don’t have hair,
you look sick.” “Looking sick” served as a constant
reminder of cancer as expressed by this 17-year-old
boy: “My hair loss reminds me of cancer. . . . I am one
of them now, and before, I just would not see it.”
“People Look at Me”
Throughout the interviews, all 5 participants
expressed that the physical changes they experienced
made them feel exposed and more vulnerable, especially those physical changes that were not easily concealable. One adolescent expressed feeling especially
vulnerable when her head was uncovered. She said,
“I feel exposed without my hat.” When asked how she
perceived her physical changes, one 15-year-old
answered, “I find myself so ugly that I am scared to go
out in a crowd because I think people will look at me.”
All 5 participants stated that the physical changes they
experienced placed them at risk of becoming noticed
by others. One 14-year-old stated, “All the time people
look at you; people judge you by the way you look.”
Another 15-year-old adolescent further illustrated this
theme: “If I show my head in public, I know people
will say I look sick.” The theme “people look at me”
brings to light an understanding of the strong emotion
that is linked to the perception that adolescents have of
204
their altered body images. It is this feeling of exposure
that drives the adolescents to develop a new set of
behaviors to cope with their new situations.
Impact of Body Image Perception on Their Life
The second part of this study examined the impact
of the adolescents’ perception of their body image
on their everyday lives. When participants described
how their altered bodies disrupted their life, 4 major
themes were identified: “avoiding social situations,”
“maintaining normality,” “peer-shield,” and “testing the
waters.” These themes are interwoven with one another
and are derived mainly from the adolescents’ sense of
exposure and vulnerability as previously described.
Avoiding Social Situations
Avoiding social situations was a theme that emerged
when participants described how their perceived image
affected their desire to see friends, to have intimate/
romantic relationships, to attend school, and to partake
in leisure activities.
Friends. Four participants chose to avoid situations in
which they were out in the open. One 14-year-old, when
asked why he was not participating in activities with his
friends since starting treatment, responded, “I don’t
want to see people. I don’t want them to see me sick.”
Moreover, those adolescents who did socialize with
their friends hesitated about doing so. When asked if
there were specific times when they did not want to go
out because of the way they looked, one 15-year-old
answered, “All the time, every time that I have to go out,
but I do it anyways.”
Intimate/romantic relationships. Four participants
clearly stated that their perceived body image had a
negative impact on intimate/romantic relationships.
In fact, 4 of 5 participants were not involved with a
girlfriend/boyfriend at the time of the interview and
expressed no desire to have one. Adolescents gave
various reasons as to why they could not be in an intimate relationship while undergoing cancer treatment.
Three adolescents stated that the way they looked was
an obstacle in finding someone who would be
attracted to them. One 15-year-old adolescent said,
“Look at me. I’m not nice looking at all; there never
will be a girl that would want to go out with me.” One
Journal of Pediatric Oncology Nursing 23(4); 2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
Changes in Body Image
girl expressed that a boyfriend could not possibly
understand what adolescents with cancer were going
through or why they look the way they did.
School. None of the participants were attending
school at the time of the interviews. Although fatigue
and time-consuming treatments were mentioned as
impeding their school attendance, 4 participants did
admit that their perceived body image affected their
desire to attend school. Participants described not
wanting their schoolmates to see them with their body
changes such as hair loss or scars. When asked when
they intended to go back to school, one 17-year-old
replied, “I don’t want to go back to school until my
hair grows back.”
Leisure activities. Four adolescents stated that their
perceived body image impeded their desire to participate in leisure activities in which their bodies might be
exposed. When asked what kind of activities they
avoided since their diagnosis, one 15-year-old replied:
I would never go to a public pool; for example,
there is a pool where I live, where there are
always 200 to 300 persons. . . . I would never go
there . . . to go there without a shirt so everybody can say, “Hey what is the big thing on his
chest; he has a big scar with a big ring” [referring to his CVC].
Maintaining Normality
This theme describes what adolescents did to hide
their negative body changes in order to maintain normality in their life. Maintaining normality can be
divided into 2 dimensions: “minimizing changes” and
“using enhancers.”
Minimizing changes. All 5 adolescents said that they
would do as much as they could to minimize and even
hide their physical changes. The physical changes that
the adolescents wanted to hide were the most noticeable ones such as hair loss (ie, wearing wig/hat) and
the presence of the CVC (ie, wearing a shirt covering
the lower end of the neck). They described that minimizing the changes they experienced secondary to
cancer allowed them not be noticed in public and to
preserve a more normal appearance. One 15-year-old,
while talking about her hair loss, expressed, “You just
buy a wig so some people won’t really notice if you
lose your hair . . . looking normal . . . like, I don’t want
no one to know what’s wrong with me.”
Using enhancers. All the participants used enhancers
to help them look more acceptable and attractive. The
most commonly used enhancers were fashion accessories and clothing that many “normal” nonsick adolescents would want. As one 17-year-old adolescent
stated, “I will try to look as good as I can . . . nice
clothes . . . the styles.” Other enhancers used by adolescents included fragrance and makeup.
Peer-Shield
All 5 adolescents in the study relied heavily on their
friends to act as protective agents against what others
might say about their body images. When asked about
how their friends helped them, one 15-year-old adolescent said, “My friends protect me against what people
are going to think about me.” Participants provided rich
descriptions of how they believed their friends surrounded them when going out, especially in a crowded
area. Some of them described their friends as acting as
a “bubble” or “safety blanket,” in other words, a shield.
One 15-year-old explained the peer-shield as follows:
My friends are not like nerds; they are not
rejects; when I am with them we are 10-15 persons together. . . . My friends, its like my metal
shield, like a bubble on top of me, if somebody
will say something about me, they won’t be
scared to defend me.
All the participants stated that friends became especially important when they were going out. As one 15year-old explained, “I need my friends, like when I go
out, I need them to be there, when I go out, more than
the parents.” In addition to describing the protective role
their friends play, 3 adolescents expressed having
a great need for their friends to accept their body
changes. One 17-year-old explained, “When I feel different, my friends are like a safety blanket.” One participant emphasized the importance of friends acting as
an intermediary between her and other adolescents by
saying, “My friends, they are like comfort. They comfort you when you need somebody to talk to, like you
know, when people want to know something about me,
they ask my friends and my friends just answer.” All 5
participants described how their friends readily assumed
the roles of protector, comforter, and intermediary without being asked. When describing the importance of a
Journal of Pediatric Oncology Nursing 23(4);
2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
205
Larouche and Chin-Peuckert
strong presence of peers in their life, all participants
highlighted the bidirectional nature of the relationship
that existed between them and their friends.
Testing the Waters
Although all 5 adolescents avoided situations in
which they felt vulnerable, 4 gave vivid examples of
how they slowly acquired the confidence to go back
to their normal active social environment. They
described choosing “secure” situations in order to test
out the reaction of others. One 17-year-old recounted
removing his hat and showing his head without hair
for the first time in public in a funeral home:
At first, I always wear my hat, stuff like that. . . .
People said, “Can I see your head?” . . . I
responded, “Not gonna happen.” . . . The first time
I removed my hat, I was at a funeral, at the viewing, without my hat on. . . . I don’t know, I kind of
caught myself, asking myself, not really asking
what am I doing, but just realizing my hat is off.
These participants shared revealing their body
changes (not wearing their hat/wig) for the first time
in a controlled and/or secure environment. A 15-yearold girl mentioned, “I take my wig off, cause sometimes it’s hot. . . . I don’t wear my wig around the
house.” Slowly testing out the way they look to others enabled the adolescents to protect their body
image. A 17-year-old boy added, “When I go out, it’s
important to be with my friends, cause they are my
testing area. . . . Like this summer, like when I go
swimming, I’m gonna run it by them.”
Limitations
The primary limitation of this study is the small
sample size, thus making it difficult to generalize the
results. The sample was also biased because it comprised only those adolescents who were willing to
participate in the study. The 1 adolescent who was
reluctant to participate may have had a different perception of her body image and used different coping
mechanisms from those described in the study.
Discussion
The findings of this study, as illustrated in the
conceptual map in Figure 1, shed new light on how
206
adolescents who undergo cancer treatment perceive
their body image as well as how their perceived body
image impacts on their daily life. The new perspectives identified by the 5 adolescents illustrate that they
perceive their body image as not normal, as looking
different from those of their peers. As a result, adolescents in this study expressed feeling vulnerable, which
serves as an emotional link between the adolescents’
perceptions and their actions. Although the literature
is extensive on the importance of peers for adolescents
with cancer (Enksar et al., 1997; Kyngas et al., 2001),
this study provides more specific information on how
adolescents draw on their friends for comfort and protection. Last, the findings illustrate how adolescents,
although struggling with physical changes, acquire
new coping behaviors that help them regain entry into
the social arena. Interestingly, most of the themes in
this study emerged from the second interview with the
participants. This suggests the need to include more
than 1 interview when using a qualitative approach to
explore the perspective of adolescents.
Peer-Shield
The literature on adolescents with cancer suggests
that the associated treatments and their side effects
have the ability to seriously disrupt adolescents’ body
image and may, consequently, lead to social adjustment problems (List et al., 1991; Varni et al., 1995)
along with poor peer relationships (Spirito et al.,
1990). However, adolescent participants in this study
revealed that in addition to entertaining good relationships with their friends, they draw on friends as
protection and to ease their adjustment to their new
physical appearance. Participants described the
“peer-shield” as a strong, caring attitude of their
friends toward them. In this study, adolescents
reported that their peer-shield did not isolate them but
rather shielded them against negative criticisms from
others.
Although previous studies have reported peer support
for adolescents as a major resource in helping them deal
with the cancer experience (Enksar et al., 1997; Fritz &
Williams, 1988), they failed to describe how they do so.
The 5 adolescents in this study discussed how their peers
assisted them in feeling accepted and helped them to
restore their social life. The findings revealed that the participants’ close friends acted as “protectors” of the sick
adolescent against others’ negative attitudes. This particular behavior conveys a strong meaning of acceptance to
Journal of Pediatric Oncology Nursing 23(4); 2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
Changes in Body Image
Diagnosis of cancer
and
Treatments
Perceptions
of
their body image
Impact of perceptions
of body image
on daily life
Maintain normality
Testing the waters
Avoidance
Adolescent with cancer
Figure 1. Conceptual Map
the sick adolescent. This feeling of acceptance permits
the adolescent, who has undergone significant body
changes, to feel normal among his or her friends. Many
authors argue the importance of cancer patients returning
to normal activities as soon as possible after the diagnosis in order to promote feelings of safety (Hilton, 1996;
Krongard et al., 1997; Kyngas et al., 2001). This feeling
of normality conveyed by the peer-shield assists the adolescent with cancer to slowly resume normal activities
within a safe surrounding. Second, adolescents in the
study also outlined that the quality of the friendship is an
essential component to having an appropriate peershield. Participants described the peer-shield structure as
including their closest friends and ranging in number
from 2 to 7 friends. This may provide new information
explaining why cancer patients have fewer friends than
their normal peers (Nichols, 1995) in that the peer-shield
does not need to be composed of many individuals in
order to be effective. Because the participants in this
study were “middle-age adolescents,” this may also
explain from a developmental perspective their preference in having quality friendships over the number of
friendships. Last, the results of the study suggest that the
peer-shield is a bidirectional relationship that takes place
between the adolescent and his or her friends.
Participants reported relying on their friends to protect
them, but they also clearly stated that their friends took
on that responsibility without solicitation. In this study,
all the participants had strong relationships with their
friends before the diagnosis. Because the participants in
this study were doing relatively well, it can be assumed
that the peer support system preceding diagnosis plays an
important role in the participants’ adaptation to their
physical changes. Therefore, it can be argued that adolescents who have poor or few relationships with friends
before diagnosis may be more at risk for psychological
distress and/or maladaptation. The results also suggest
that the peer-shield is distinct from parental support
because its usefulness arises mainly when the adolescent
is outside the family home. Consequently, the peer-shield
is thought to be unique in providing a specific type of
support for adolescents with cancer.
Testing the Waters
Several authors report that adolescents with cancer
tend to be more isolated than are their healthy peers
(Noll et al., 1991), whereas others report that adolescents with cancer are resilient and able to adapt to their
new situations (Grootenhuis & Last, 2001; Trask et al.,
2003; Woodgate, 1999). The present study reveals that
for adolescents undergoing cancer treatment, exposing
their body changes in public is a threatening situation.
The primary appraisal of this situation is threatening
for adolescents and leads to a secondary appraisal that
entails the evaluation of their capacities and resources
to deal with the stressful circumstance (i.e., potential
coping options) (Lazarus & Folkman, 1984). In this
study, 1 of the coping options used by adolescents to
deal with their body changes was “testing the waters.”
Four of the participants described how they gradually
re-entered their social scene by exposing their physical
self in specific nonthreatening or secure environments.
Journal of Pediatric Oncology Nursing 23(4);
2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
207
Larouche and Chin-Peuckert
Based on the findings of the present study, we
believe that the friends’ supportive attitude toward
adolescents with cancer when they first revealed their
body changes contributed to their successful social
adaptation. It can also be argued that successful social
adaptation from using a “testing the waters” approach
strongly depends on the degree of cohesion of the
adolescent’s peer-shield structure.
themselves as looking different from their peers. This
altered body image may lead them to feel exposed.
The peer-shield they identified protects the adolescent and is also important in helping the adolescent
feel normal. Once they feel accepted by their friends,
adolescents use progressive testing behaviors to
adjust to their physical appearance and reintegrate
into their social life.
Implications for Nursing Practice
Although the 5 adolescents in this study were well
adapted, it is possible that adolescents without strong
peer support systems may not adjust as well to the
effects of cancer and the treatment. Nurses who work
in pediatric oncology settings can explore with adolescents their peer-shield, especially at the onset of diagnosis. The finding that strong peer support may help
promote adaptation can help the health care professional to target those adolescents with poor peer support and plan interventions accordingly. Nurses can
assist sick adolescents to foster the building of the peershield by helping them identify who their friends are
and how to communicate with them. In addition, nurses
can educate the adolescent’s friends on how to support
the adolescent with cancer. Nurses can initially assess
whether adolescents’ perceptions of their body image
are a threat to their well-being and can identify different coping strategies used by adolescents and evaluate
their effectiveness. Last, nurses can assist adolescents
to explore safe activities in which they would be able to
expose themselves without feeling vulnerable.
Future Research
Further studies with a larger sample are needed to
determine if the results of this study can be replicated.
The new information identified here has not emerged
from previous quantitative studies, thus supporting the
need for future qualitative research to understand the
lived experiences of adolescents with cancer.
Conclusion
This study explored the perceptions of body
image of adolescents with cancer and the impact of
body image changes on their daily lives. The findings
describe how adolescents with cancer perceive
208
Acknowledgment
We express our sincere gratitude to the adolescents
who agreed to share their experiences. We acknowledge the support of the hematology/oncology team of
the Montreal Children’s Hospital. We also thank Lucie
Caron for her participation in the project. We are grateful to Sasha Dubrovsky for reviewing the manuscript
and his ongoing support throughout this project.
References
Aasland, A., & Diseth, T. H. (1999). Can the Harter Self-Perception
Profile for Adolescents (SPPA) be used as an indicator of psychosocial outcome in adolescents with chronic physical disorders? European Child & Adolescent Psychiatry, 8, 78-85.
Dashiff, C. (2001). Data collection with adolescents. Journal of
Advanced Nursing, 33, 343-349.
Eiser, C. (1996). The impact of adolescents’ views. In P. Silby &
C. Bailey (Eds.), Cancer and the adolescent (pp. 264-275).
London: BMJ.
Eiser, C., Hill, J. J., & Vance, Y. H. (2000). Examining the
psychological consequences of surviving childhood cancer:
Systematic review as a research method in pediatric psychology. Journal of Pediatric Psychology, 25, 449-460.
Enksar, K., Carlsson, M., Golsater, M., & Hamrin, E. (1997).
Symptoms distress and life situation in adolescents with cancer. Cancer Nursing, 20, 23-33.
Erickson, E. (1963). Childhood and society (2nd ed.). New York:
Norton.
Fritz, G. K., & Williams, J. R. (1988). Issues of adolescents and
young adults’ psychosocial concerns, coping strategies, and
interventions. Cancer, 71, 3276-3280.
Glasson, J. E. (1995). A descriptive and exploratory pilot study into
school re-entrance for adolescents who have received treatment
for cancer. Journal of Advanced Nursing, 22, 753-758.
Grootenhuis, M. A., & Last, B. F. (2001). Children with cancer
with different survival perspectives: defensiveness, control
strategies, and psychosocial adjustment. Psycho-Oncology,
10, 305-314.
Hedstrom, M., Haglund, K., Skolin, I., & Von Essen, L. (2003).
Distressing events for children and adolescents with cancer:
Child, parent, and nurse perceptions. Journal of Pediatric
Oncology Nursing, 20, 120-132.
Journal of Pediatric Oncology Nursing 23(4); 2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
Changes in Body Image
Hilton, B. A. (1996). Getting back to normal: The family experience during early stage breast cancer. Oncology Nursing
Forum, 23, 605-614.
Hinds, P. S., & Martin, J. (1988). Hopefulness and the self-sustaining process with adolescents with cancer. Nursing Research, 37,
336-340.
Krongard, A., Granville, L. J., Burke, M. A., Golden, R. M., Lais,
C. L., & Niederberger, C. S. (1997). Predictors of general
quality of life in patients with benign prostate hyperplasia or
prostate cancer. Journal of Urology, 157, 534-538.
Kyngas, H., Mikkonen, R., Nousiainen, E-M., Rytilahti, M.,
Seppanen, P., Vaattovaara, R., et al (2001). Coping with the
onset of cancer: Coping strategies and resources of young people with cancer. European Journal of Cancer Care, 10, 6-11.
Lansky, S. B., List, M. S., Ritter-Sterr, C., & Hart, M. J. (1993).
Pediatric and psychological support of the child and adolescent
with cancer. In P. A. Pizzo & D. G. Poplack (Eds.), Pediatric
oncology (pp. 1127-1139). Philadelphia: Lippincott.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer.
List, M. A., Ritter-Sterr, C., & Lansky, S. B. (1991). Cancer
during adolescence. Pediatrician, 18, 32-36.
Nichols, M. L. (1995). Social support and coping in young
adolescents with cancer. Pediatric Nursing, 21, 235-240.
Noll, R. B., LeRoy, W. M., Bukowski, W. M., Rogosh, F. A.,
Davies, W. H., Rogosch, F. A., et al. (1991). Peer relationships
and adjustment in children with cancer. Journal of Pediatric
Psychology, 16, 307-326.
Palmer, L., Erickson, S., Shaffer, T., Koopman, C., Amylon, M.,
& Steiner, H. (2000). Themes arising in group therapy for
adolescents with cancer and their parents. International
Journal of Rehabilitation and Health, 5, 43-54.
Pendley, J. S., Dalhquist, L. M., & Dreyer, Z. (1997). Body image
and psychosocial adjustment in adolescent cancer survivors.
Journal of Pediatric Psychology, 22, 29-43.
Puukko, L. R., Sammallahti, P. R., Siimes, M. A., & Aalberg, V. A.
(1997). Childhood leukemia and body image: Interview
reveals impairment not found with a questionnaire. Journal of
Clinical Psychology, 53, 133-137.
Schilder, P. (1950). The image and appearance of the human
body: Studies in the constructive energies of the psyche. New
York: International Universities Press.
Spirito, A., Stark, L. J., Cobiella, C., Drigan, R., Androkites, A., &
Hewett, K. (1990). Social adjustment of children successfully
treated for cancer. Journal of Pediatric Psychology, 15, 359-371.
Stiller, C. (2002). Epidemiology of cancer in adolescents. Medical
and Pediatric Oncology, 39, 149-155.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research:
Techniques and procedures for developing grounded theory.
Thousand Oaks, CA: Sage.
Thompson, J. (1990). The child with cancer. London: Scutari Press.
Trask, P. C., Paterson, A. G., Trask, C. L., Bares, C. B., Birt, J., &
Maan, C. (2003). Parent and adolescents’ adjustment to pediatric cancer: Associations with coping, social support, and family function. Journal of Pediatric Oncology Nursing, 20, 36-47.
Vannatta, K., Gartsein, M. A., & Noll, R. B. (1998). A controlled
study of peer relationships of children surviving brain tumors:
Teacher, peer, and self-ratings. Journal of Pediatric Psychology,
23, 279-287.
Vannatta, K., Zeller, M., Noll, R. B., & Koontz, K. (1998). Social
functioning of children surviving bone marrow transplantation. Journal of Pediatric Psychology, 23, 169-178.
Varni, J. W., Katz, E. R., Colegrove, R., & Dolgin, M. (1995).
Perceived physical appearance and adjustment of children
with newly diagnosed cancer: A path analytic model. Journal
of Behavioural Medicine, 18, 261-278.
Wasserman, A. L., Thompson, E. I., Wilimas, J. A., & Fairclough,
D. L. (1987). The psychological status of survivors of childhood/adolescent Hodgkin’s disease. American Journal of
Diseases of Children, 141, 626-631.
Weekes, D. P., & Kagan, S. H. (1994). Adolescents completing
cancer therapy: Meaning, perception and coping. Oncology
Nursing Forum, 21, 663-670.
Weekes, D. P., & Savedra, M. C. (1988). Adolescent cancer: Coping
with treatment-related pain. Journal of Pediatric Nursing, 3,
318-328.
Whyte, F., & Smith, L. (1997). A literature review of adolescence
and cancer. European Journal of Cancer Care, 6, 137-146.
Woodgate, R. L. (1999). A review of the literature on resilience in
the adolescent with cancer: Part II. Journal of Pediatric
Oncology Nursing, 16, 78-89.
Woodgate, R. L. (2000). Part II: A critical review of qualitative
research related to children’s experience with cancer. Journal
of Pediatric Oncology Nursing, 17, 207-228.
Yin, R. K. (2002). Case study research: Design and methods
(3rd ed.). Thousand Oaks, CA: Sage.
Journal of Pediatric Oncology Nursing 23(4);
2006
Downloaded from jpo.sagepub.com at PENNSYLVANIA STATE UNIV on September 18, 2016
209