The present study was conducted to identify body image distress among patients with head and neck cancer attending follow-up services at a newly established tertiary care hospital, North India. The mean age of patients was 47.98 (±12.1) years, with a higher proportion of male patients than female patients. These demographics were found in concurrence with the previous epidemiological study, which reported higher head and neck cancer incidence in the age group of 40-60 years and sixteen times higher in the male population conducted in Western Uttar Pradesh. Likewise, these demographic trends were found similar in other work conducted in southern states of India . Demographics trends further supported with other relevant literature emphasizing 2-4 times higher risk of head and neck cancer in men than women .
In clinical profile, oral cancer reported more frequent cancer in the head and neck with a mean duration of 11.55 (±6.91) years. Further, a greater number of patients were undergoing a combination of treatment, including chemotherapy, radiation, and surgery. These demographics are in line with the study from India reported 40% of oral cancer, where cancer of the tongue and mouth contributed more than one-third of total cancer . However, a decline in trends for oral cancer was observed in men above 40 years of age during 1986-2000, but this trend remains unchanged in adult men below the age of 40 . The possible reason for the sudden decline of oral cancer in a group may be postulated with the declining use of tobacco. However, a very higher incidence of cancer indicates continued use of tobacco and alcohol in the population. Excessive alcohol use (42.9%) and tobacco use (20%) were observed in the current cohort, higher in female patients. Besides tobacco use, the harmful effects of alcohol and other paan products are clear risk factors for oral cancer in India and elsewhere [20, 21]. Further, it has been attributed that regular alcohol use increases the risk of oral cancer . Likewise, smoking and alcohol use further intensify the incidence of oral cancer compared to alcohol use only [22, 23].
Further, the mean scores of body image distress were 57.95 ± 10.3, ranging from 42-77, suggesting higher distress among head and neck cancer patients. The higher distress in patients shall be correlated with dissatisfaction with personal appearance or disfigurement after surgery . A similar result was found in earlier work on a head and neck cancer patient . Likewise, other concerns noticed among surgically treated head and neck cancer patients were negative body image and overall poor quality of life [12, 25]. The incidence of negative self-evaluation about the health dimension of body image, appearance, and not being attractive or embarrassed about bodily changes is very well documented in cancer patients . In a qualitative investigation, disfigurement reported a constant reminder for ruptured self-image and other dysfunctions in cancer patients . However, the prevalence of body image distress varies, which ranges 25-77%, higher in newly diagnosed younger patients .
Age, gender, and working status of patients with head and neck cancer reported a significant association with body image associated distress. Findings said that younger patients (<40 years) felt more distress while shopping in a departmental store. Conversely, the adult cohort reported a feeling of rejection and distress while playing sport. These findings on distress are consistent with the work conducted at Netherland said higher distress among younger age cohort while having social interactions . Likewise, male patients were more embarrassed while using communal changing rooms, and refraining from visiting restaurants and public places is more frequently observed in the female cohort. A qualitative investigation reported that patients with this kind of cancer face more problems while eating in public places or restaurants while holding the fluid in their mouth, starring people, and prothesis-related issues that further potentiate frustration and embarrassment .
Body image distress is more common in young patients with cancer considering being more apprehensive and feeling isolated and rejected . Patients expressed negative body image experiences related to the asymmetric appearance of the face and created an older look. However, it has been reported by the patients that it will take a longer time for them to restore normalcy in working, living, or sports . Saying that anxiety before joining the work after facial surgery and different attitude of supervisors or colleagues after surgery may potentiate to quit a job . Further, disfigurement associated with poor self-esteem and higher body image-related distress may also impede the normal grieving process and may take a longer time for patients to restore everyday living .
Females cancer cohort reported higher body image-related distress than male counterparts. Facial disfigurement has a higher negative impact on female patients than male patients and may have a negative effect on body image . In general, women are more sensitive about their appearance and appreciate and associate beauty as their emotional strength [28, 31], This could be a probable reason for higher body identity-related stress in the female cohort, similar to earlier findings on a female with head and neck cancer.
However, the study should be appraised under many limitations. First, a one-time cross-sectional survey may not attribute cause and effect relationships. Secondly, the response to body identity associated self-distress was self-reported and hence may carry subjective reporting bias and should be extrapolated carefully. Third, the study was conducted in a single center; even though one of the largest institutes in the regions consequently, the findings' generalizability might be limited to the area only. Finally, the phenomenological approach would best explore the cause of body identity-associated distress in a real-time scenario in the study cohort.