The impact of mastectomy on body image and sexuality in women with breast cancer: a systematic review

: Objective: The study aims to evaluate the impact of mastectomy on body image and sexuality of women with breast cancer, as well as to provide a general understanding of their quality of life. Method: This review followed the PRISMA guidelines. The expression “Mastectomy AND (sexuality OR “body image”)” was searched in Lilacs, Scielo, Pubmed and Scopus databases. Articles published in English, Portuguese and Spanish between 2010 and 2020 were selected. The text analysis was carried out by peers. Results: 69.3% (43) of the studies presented mastectomy as a technique that worsens body image, sexual functioning and quality of life of women. Less radical procedures, such as breast-conserving surgery, showed lower impact on these indicators. Breast reconstruction is an alternative to mitigate breast surgery impacts. Conclusion: Mastectomy caused the major impacts on body image, sexual functioning and quality of life. These implications need to be considered during therapeutic choice.


Introduction
Globally, breast cancer is, excluding non-melanoma skin cancer, the most frequently diagnosed cancer in women, and the commonest cause of cancer death among this group (1) . In 2018, about 2.1 million new cases of breast cancer and 627 thousand deaths were estimated (2) . Although the incidence of breast cancer is lower in regions of medium and low income, the developing countries reveal the highest mortality rates (1) .
Breast cancer is a malignancy of the breasts that causes breast symptoms and changes, such as lumps, localized pain, nipple symptoms or skin alterations (3) . In early breast cancer without metastasis, women undergo breast surgery and, commonly, need a form of systemic therapy (3) . Surgical treatment is done mainly through either mastectomy or breast-conserving surgery. Currently, studies (4)(5)(6) have demonstrated equivalence in overall survival between both surgical techniques. Thus, in the absence of medical contraindications, the decision for which surgical therapy should be used becomes a personal matter.
In a mastectomy, women experience entire breast removal, thereby resulting in a permanent change in their appearance (7) . In this regard, besides the complications arising from the illness, breast cancer and its treatment have repercussions caused by the total or partial mutilation of the breast, often resulting in problems associated with body image (BI), self-acceptance, sexuality and quality of life (QoL) (8) .
BI is a psychological construct about perceptions, emotions and attitudes that individuals hold towards their own body (9) . In breast cancer, treatment can affect BI, as the loss of an organ full of symbols and identity brings to the survivors dissatisfaction with appearance, perceived loss of femininity and body integrity, reluctance to look at one's self naked, as well as feeling less sexually attractive (10) . Furthermore, the perception of BI is a key determinant of QoL (7) .
Sexuality is an essential aspect of the life of cancer patients. Nonetheless, an impaired sexuality is highly prevalent among those who experience cancer, especially breast cancer, which emphasizes suffering and worry about the disease, also damaging QoL (11) . Certainly, the loss of the whole breast, a secondary sex organ, causes a variety of psychological changes and sexual complaints, including loss of attractiveness and decreased sexual interest, excitement and orgasms (12) .
BI and sexuality are important factors in the QoL of women with breast cancer. Besides, it is widely accepted that mastectomy represents a considerable disruption in these aspects. Therefore, studying post-surgical sexuality and BI proves to be relevant to health care planning, for both health professionals and public health policies. Moreover, in therapeutic planning, patients should be informed not only about the impact of surgery on cancer remission but also on health-related QoL. This includes information about possible changes in BI and sexual well-being. Although data regarding the QoL of patients with breast cancer are found in the literature, there is a lack of reviews with a specific focus on BI and sexuality after mastectomy.
Thus, this systematic review aims to comprehend how mastectomy impacts BI and sexuality of women who have undergone breast cancer treatment, as well as to provide a general understanding of these patients' QoL.

Materials and Methods
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Search strategies and eligibility criteria
A bibliographic search was conducted on June 2, 2020, in the following databases: Lilacs (Literatura Latinoamericana y del Caribe en Ciencias de la Salud), Scielo (Scientific Electronic Library Online), Pubmed and Scopus. The search terms used were "Mastectomy AND (sexuality OR "body image")". Filters were also applied regarding language and publication date, and only texts in Portuguese, Spanish or English, published between 2010 and 2020, were selected.
Accordingly, 1221 articles were identified through this search. Duplicates between databases were excluded and the remaining texts underwent an evaluation of their title, abstract and keywords. This analysis was performed by peers, and the divergences were solved by a third reviewer. For this purpose, the criteria described in Table 1 were used. After this process, publications that did not meet the inclusion criteria were excluded and the remaining articles were retrieved for a full-text assessment.
Then, the selected texts were fully read. It is noteworthy that this assessment was also carried out by peers, with disagreements resolved by a third reviewer. Articles that did not fit the selection criteria (depicted in Table 1) or did not have the full text available were excluded. At the end of this process, 62 articles were selected for inclusion and analysis in this review. Articles with an approach out of the context of the investigated subject; Articles published between 2010 and 2020; Articles from literature review studies; Studies with empirical results; Articles in the form of dissertation, thesis, book chapter, book, manual, editorial, review, comment, criticism, report, letter, note, conference paper and manuscript; Studies that addressed mastectomy as a treatment for breast cancer and analyzed its impact on women's body image and / or sexuality; Articles that addressed the body image of women who underwent prophylactic mastectomy, whether they did not have breast cancer or underwent contralateral breast removal; Articles that addressed breast cancer exclusively in women; Studies that included only women who had breast reconstruction surgery or only women who had breast-conserving surgery; Articles that addressed these issues from the perspective of mastectomized women and not according to the perception of other people towards them.
Studies performed with women who had breast cancer recurrence or metastasis; Articles that addressed other people's perceptions of mastectomized women; Studies that did not use validated scales to measure results.

Data extraction and synthesis
Data from the included publications were extracted. Then, a table was created and the following variables were established to be collected: First author, year and country; Sample group; Age of participants (mean and range); Surgical procedure(s); Questionnaire(s) applied and Results (Table 2). A pilot test was carried out with 5 randomly chosen articles and, later on, all the included texts were tabulated. This work was conducted by two independent reviewers, with divergences being evaluated by a third reviewer. It is important to highlight that, in the "Results" column, the main findings of the studies related to the topic addressed in this review were summarized, but the results not associated with the present analysis were not described, such as data related to arm symptoms and to the development of depression after mastectomy. Finally, the extracted data were assessed according to the objective of this work.

Results
1221 articles were identified (36 at Lilacs, 18 at Scielo, 556 at Pubmed and 611 at Scopus), of which 389 were excluded due to duplication between databases, thus remaining 832 texts for analysis. Then, in the first evaluation stage, based on reading the title, abstract and keywords, 709 papers that did not meet the inclusion criteria were excluded. The remaining 123 publications were fully examined. Of these, 61 were excluded, 55 for not meeting the selection criteria (Table 1) and 6 for not having the full text available. At the end of this process, 62 articles were selected for data extraction and inclusion in this review ( Figure 1). Mastectomy was seen in the given studies as a factor that affects several areas of the life of women with breast cancer. In this review, an analysis was carried out focusing on its repercussions on the BI, sexual functioning (SF) and QoL of these patients.
The included articles approach the impact of mastectomy on QoL, SF and BI of women with breast cancer, also bringing a comparison with the impact of other surgical treatments, such as breast-conserving surgery, lumpectomy and breast reconstruction. The total number of participants in the analyzed studies was 10877. The minimum and maximum age of the patients were 18 and 94 years, respectively. The mean age of participants among the studies that brought that information was 51.4 years. 61 different questionnaires were used in the studies, among which the most frequently used were: (EORTC QLQ-BR23) in 19 studies (30.6%), (EORTC QLQ-C30) in 18 studies (29.0%), (FSFI) in 14 studies (22.6%) and (BIS) in 12 studies (19.3%).

Body Image
BI was addressed in 64.5% (40) of the analyzed articles. Mastectomy was a major impact factor in the BI of women with breast cancer in 46.7% (29) of the studies, both in short and long term. Furthermore, 24.2% (15) of the texts showed that the impact of mastectomy was worse than that of other surgical treatments (breast-conserving surgery, lumpectomy and breast reconstruction). In addition, the damage was greater in mastectomized patients when compared with the control group in 1.6% (1) of the articles.
Breast-conserving surgery was the second type of surgical treatment for breast cancer that had the most negative repercussions in BI. Nevertheless, in 3.2% (2) of the texts, the losses caused by mastectomy and breast-conserving surgery in BI were comparable.
Breast reconstruction is an effective way to improve the BI of women after surgical treatment for breast cancer, which was seen in 4.8% (3) of the articles. However, 2 other studies reported that delayed reconstruction had a negative effect on BI. Moreover, 1.6% (1) of the texts concluded that breast cancer patients who did not receive any surgical treatment showed a more impaired BI than those who did.
Finally, 1.6% (1) of the articles associated better BI with an investment in selfcompassion and appearance. Furthermore, another article (1.6%) related worse BI with post-treatment weight gain. Also, 1 article revealed that women who underwent nipple-sparing mastectomy with immediate reconstruction had moderately low levels of BI disorders.

Sexuality
Sexuality is directly affected by the surgical treatment of breast cancer. Thus, an association between breast surgery and impaired SF or sexual dysfunction (SD) was shown in 56.4% (35) of the assessed articles. Mastectomy harmed SF or caused greater SD in 4.8% (3) of the studies. Several texts brought a comparison between the types of treatment regarding their impact on women's sexuality: 8 articles showed that mastectomy had a worse impact on SF or caused greater SD when compared with breast-conserving surgery. Conversely, 2 other articles concluded that conservative surgery was worse for SF than mastectomy. Yet, another 3 studies demonstrated that both mastectomy and breast-conserving surgery similarly worsened SF or contributed to the development of SD. Moreover, 1.6% (1) of the articles exhibited that worse SF was associated with post-treatment weight gain.
Regarding lumpectomy, 4.8% (3) of the articles revealed better results in SF or less SD when compared with mastectomy. Furthermore, 3.2% (2) of the studies reported that SF was more affected in mastectomized women than in the control group. Additionally, 2 texts showed that SF has a strong tendency to decline over time. Also, it was evident that breast reconstruction is a viable alternative to improve SF, given that 17.7% (11) of the articles correlated it with improvements on SF or lower SD. Moreover, one study noted that SF is directly related to the age of the patients.
Remarkably, 1.6% (1) of the articles reported the existence of a positive correlation between SF and BI, and another study showed that partners' support also correlates with SF scores. Moreover, in 6.4% (4) of the texts, circumstances such as absence of partner, high level of education, absence of breast reconstruction, advanced age and marital status were associated with greater SD. Yet, another article (1.6%) showed that lower levels of education and having an older partner were contributing factors for worse SF. Furthermore, 1 article (1.6%) associated younger age, being married and elementary education level with worse SF. However, 1.6% (1) of the studies showed that SF improved as the education and income of women with mastectomy increased.

Quality of Life
QoL is another aspect that is greatly impaired by procedures that modify the patient's body shape, such as mastectomy, and was addressed in 32.2% (20) of the selected articles. 24.2% (15) of the studies mentioned an association between QoL and mastectomy: 6.4% (4) simply showed that the procedure negatively affected QoL; 9.7% (6) reported that breast-conserving surgery would be better than mastectomy in terms of QoL, and 1.6% (1) pointed out that lumpectomy had less significant impacts on QoL than mastectomy.
Moreover, 3.2% (2) of the articles concluded that the QoL of mastectomized women improved over time. Furthermore, 2 studies showed that, concerning QoL, breast-conserving surgery was worse than mastectomy, with age influencing in these cases: younger women have a positive impact with mastectomy, but older women do not. Also, 1.6% (1) of the studies reported that younger women had their QoL more affected by surgery when compared with older women. Nevertheless, 1.6% (1) of the articles showed some similarity in the perception of QoL between patients who underwent mastectomy and those who underwent breast-conserving surgery. Also, 4.8% (3) of the texts reported breast reconstruction as an effective way to mitigate the damage of surgery in patients' QoL. Finally, in 1.6% (1) of the articles, there was a positive correlation between BI and QoL.  However, women who had undergone breast-conserving surgery seemed to have slightly better conditions than mastectomized ones.
(2020), United States (19) 585 -Mastectomy (nipple-sparing or not), nipple-sparing mastectomy with breast reconstruction, non-nipplesparing mastectomy with breast reconstruction and lumpectomy (FSFI) and (*) Women who underwent lumpectomy reported better QoL (satisfaction with appearance, comfort in being seen undressed, breast's role during intimacy and pleasurable breast caress) than mastectomized women, even when compared with those who had undergone nipple-sparing surgery followed by reconstruction.

Sample group Age (mean and range)
Surgical procedure(s)
(2012), Egypt (26)   Mastectomy and breastconserving surgery (HRQoL 15D) and (BDI) Mastectomy was associated with better health-related QoL when compared with breast-conserving surgery. Among younger women, having a mastectomy instead of conservative surgery led to a positive impact on QoL, which did not happen with older women.
The older group had more habitual activities and sexual relations.
(2018), Nepal (45)  Women who had undergone reconstruction showed higher satisfaction with breast and sexual well-being than those who underwent mastectomy alone. Type (autologous or implant) and moment (immediate or delayed) of reconstruction did not seem to influence results.

Body Image
BI is not restricted to the perception of the physical appearance of the body itself, once it also involves psychological, social and cultural facets. Thus, removal of the breast, an organ full of meanings and social representations, can cause serious changes in women's body perception (73) .
Overall, the results of this review showed that mastectomy is a major impact factor on the BI of women with breast cancer, both in short and long term. Indeed, when compared with other forms of surgical treatment (such as breast-conserving surgery), radical breast removal revealed worse levels of satisfaction with BI. These results reinforce the findings of other reviews, which also argue that mastectomy has a greater impact on BI than other surgical modalities (74,75) . According to Aureliano (76) , the breast has a strong symbolic meaning, for being part of the social conception of womanhood. Hence, mastectomy represents a fragmentation of the female body, in which the symbol of women's femininity and sexuality becomes disposable. In this regard, even after cure, the breast removal leaves a permanent mark on the perception of their own body (76) .
Furthermore, breast reconstruction proved to be an important way of restoring a complete BI in some articles. This can be justified by the fact that this surgery seeks to rebuild the breasts' symbolic representation, offering women a BI closer to what is socially established as "normal" and feminine (76) . This result is consistent with the findings of the review performed by Santos and Vieira (74) , that understood reconstruction as a valuable tool for improving BI.
Given the symbolic importance of breast, as well as the potential positive effects of reconstruction, yet another result of this review can be explained: the low levels of BI disorders among patients who underwent nipple-sparing mastectomy with immediate breast reconstruction. After all, the nipple is extremely important for the full function and recognition of the breast and its preservation can reduce the feeling of mutilation, thus allowing a result closer to the original breast after reconstruction (77) . Importantly, a minority of studies have shown evidence that delayed reconstruction can impair BI. As reported by Aureliano (76) , reconstruction, despite its opposite goal, can generate the feeling of a transformed, reconstructed body for many women. Therefore, it could be understood as another mutilation, a useless modification (76) . This would explain why, when performed late in the process of readaptation and reformulation of one's body perception, reconstruction negatively affected the BI of certain women included in this review. Such results add to what is stated in the research conducted by Almeida et al. (75) , which concluded that there is no consensus about the impact of reconstruction, whether immediate or delayed, on the BI of women with cancer.
The studies also depicted other factors that influence levels of satisfaction with BI, besides the type of surgical procedure. Investment in self-compassion and appearance was associated with better BI, whereas weight gain after treatment with worse BI. According to Oliveira et al. (73) , women undergo, after mastectomy, a complex process of accepting their "new body", which suffers great external influence and depends largely on social approval. Hence, the importance of investing in self-compassion, once it allows women to value BI without depending on external validation. Furthermore, the weight stigma and the modern "beauty standards" can make the fat body seem inadequate, not acceptable (78) . This factor can make people feel undesirable and seriously affect BI, but this is even further enhanced by the loss of the breast. Therefore, it is natural to understand that the body acceptance of mastectomized women who gain weight after treatment is more severely affected.

Sexuality
Sexuality involves the integration of different dimensions, including the individual, the cultural, the physical, the affective and the social. As breast removal interferes in many of them, it also manifests itself as an amputation of sexuality, desire, feeling of femininity and attractiveness (79) .
Overall, mastectomy has proved to be a major impact factor in the SF of women with breast cancer, when compared not only to the control group, but also to the surgical modalities of breast-conserving surgery and lumpectomy. According to Vaziri and Lotfi-Kashani (80) , the ability to achieve a healthy SF involves psychological and physical factors that affect the sexual response cycle, for example, desire, arousal and orgasm. Furthermore, breasts carry a strong symbolic content as an attribute of female beauty, attractiveness and sexual identity of women (73) . Thereby, total breast removal affects specific aspects of SF and intimacy and manifests as a mutilation of the female body, causing changes in the understanding of one's sexual self.
Moreover, breast reconstruction was correlated with improvements in SF or associated with a lower risk of SD, thus representing a promising alternative to restore and improve SF. As reported by Hart et al. (81) , this is explained by the fact that the reconstruction gives women back the feeling of normality and the symbolism that the organ carries, acting in the maintenance of femininity, the feeling of sexual attractiveness and confidence during intimate relationships. These findings are consistent with the review conducted by Gilbert et al. (82) , wherein mastectomy compared with breast-conserving surgery or reconstruction was shown to result in greater feelings of body shame, reluctance to look at one's body, a negative BI, and a lower perceived sexual attractiveness. In turn, Santos et al. (83) stated that there was no consensus in the literature regarding which surgical modality has the least adverse consequences for SF of women with breast cancer.
Factors including post-treatment weight gain, time elapsed after surgery, age, education level, marital status, presence or absence of a partner, partner support, age of the partner, BI and income were either positively or negatively correlated with SF. Conforming to Male et al. (84) , post-treatment weight gain is associated with feelings of distress and worse BI, which explains a more impaired SF in these women. The SF deterioration over time observed in two articles was also noticed in the review conducted by Boswell and Dizon (85) , which argued that, although some problems improved over time, SF was not one of them.
Despite divergences in the included studies on the impact of age on SF, Chang et al. (86) described that older women give less importance to the breasts and the deterioration of intimate relationships, and also worry less about their reproductive functions. Moreover, partner support was shown to be associated with better SF, however, marital status and the presence or absence of a partner were controversial. About this subject, Chang et al. (86) also stated that partners are valuable sources of support for women with breast cancer, but having a partner that does not provide support is harmful.

Quality of Life
The development of a woman's QoL is related to a variety of factors, including her body perception. Considering the role of the breasts in sensuality and in feminine aesthetics, their major influence in this process becomes evident. Hence, since mastectomy promotes breast removal, the procedure can cause great impacts on patients' QoL (73) .
In general, the results of the present study referred that mastectomy negatively influenced the QoL of patients with breast cancer. After all, partial or total breast removal can cause complications to sexual health, to practice of physical and domestic activities and to family life, once this organ is full of symbolism and female identity, directly affecting women's self-esteem (87) . There was also evidence that, over time, women tend to have progressive improvements in QoL. Given that there is a disruption of the female body's integrity with mastectomy, time is necessary so that they can accept this change and rebuild their BI (76) .
When compared to the modalities of conservative surgery, mastectomy showed greater impact on women's QoL in most studies. The advantage of breast-conserving surgery can be explained by its association with a more positive BI (88) , since it promotes less body modification. This reinforces the data presented in the systematic review conducted by Simeão et al. (87) , which concluded that mastectomized women without reconstruction had worse QoL scores.
Moreover, in some studies, breast reconstruction has proved to be an important way of mitigating the damage caused by mastectomy on QoL. Previous research associated BI to QoL, indicating that these factors have a strong positive correlation. The systematic review by Cordova et al. (89) also showed positive results for patients who underwent breast reconstruction, justified by the aesthetic concern with their bodies. After all, in a context of overvaluation of aesthetic standards and body stereotypes, women who undergo total breast removal often feel frustrated and may develop subsequent psychosocial problems.
Another factor associated with QoL levels was the age of the participants, however, there were controversies regarding the influence exerted by it. Younger age was sometimes related to a more positive impact of mastectomy when compared with conservative surgery, which can be explained by the fear of cancer recurrence and the concern of younger women to heal themselves to care for their children and family (76) . Nonetheless, in other studies, younger age was associated with a greater impact on QoL after surgery, which can be justified by the greater tendency of younger women to be concerned with physical appearance, femininity and sexuality (90) .

Limitations
Some limitations observed in the present study were the non-inclusion of books and the so-called "gray literature" in the search for articles and the non-use of a mechanism to assess the risk of bias in the analyzed studies.
A strength of this review was the analysis of articles that used exclusively standardized questionnaires. Notwithstanding that, many different and sometimes generic questionnaires were applied, which complicated the assessment and standardization of results.
Finally, most of the articles included in this literature review evaluated aspects related to BI, SF and QoL in only one moment of patients' lives. Therefore, their evolution over time and in long term was only considered in a few studies

Conclusion
Published data regarding BI, sexuality and QoL of mastectomized women were analyzed in this review. The majority of studies pointed out evidence that mastectomy is the surgical modality that causes the greatest impact on BI and sexuality, including impairment on QoL. In addition, breast reconstruction proved to be a procedure capable of improving patients' BI, SF and QoL, especially if performed immediately.
There are also factors (investment in self-compassion, weight gain after surgery, age, marital status, among others) that can either positively or negatively influence the BI, SF and QoL of women after mastectomy. Another relevant variable was time after surgery: there was evidence of progressive improvement in QoL and acceptance of BI over the years. Adversely, there may be deterioration in SF.
Concerning the practical implications of this review, physicians should, whenever possible, take into account throughout the therapeutic choice the disorders that mastectomy may cause and provide options to the patients. Furthermore, women must be informed about the impacts of mastectomy on BI, SF and QoL in order to have greater autonomy in the process of choosing a therapeutic method.
Finally, only a small number of studies explored the evolution of BI, SF and QoL over time. Likewise, there was a lack of specific data on the interference of factors, such as age and marital status, in BI, SF and QoL, as they still remain controversial in the present literature. Therefore, it is pivotal that new studies develop these questions. After all, they are relevant to the professional who seeks to better guide patients on how the types of surgery impact the QoL of women with breast cancer.