Effects of the appearance care on psychosocial outcomes for breast cancer: a systematic review and meta-analysis

To synthesize the evidence for the immediate and short-term effects of appearance care on psychosocial outcomes in breast cancer patients in order to inform the design of future research and clinical practice. A search of four databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science). The JBI Critical Appraisal Checklists were used by two reviewers to assess methodology quality. Subgroup analysis was conducted for the different time points measured after intervention. Seven studies were eligible for the meta-analysis, including two RCTs and five quasi-experimental studies, from 1994 to 2022. The type of intervention was mainly grouped education, led by beauty specialists, and the dose and frequency varied. The quality of included studies was moderate to high. The results showed that appearance care had positive immediate effect on self-esteem (SMD = 0.63, 95% CI 0.37 to 0.89), anxiety (SMD =  − 0.46, 95% CI − 0.60 to − 0.31), and depression (SMD =  − 0.41, 95% CI − 0.62 to − 0.19), with short-term effects on anxiety (SMD =  − 0.42, 95% CI − 0.54 to − 0.34), depression (SMD =  − 0.41, 95% CI − 0.55 to − 0.26), and sexual function (SMD = 0.50, 95% CI 0.18 to 0.81).The effect of appearance care on body image and quality of life was uncertain. Appearance care could be a promising intervention to improve self-esteem, anxiety, depression, and sexual function among patients with breast cancer. More high-quality RCTs are needed to validate these findings. Online appearance care programs and exploration of long-term effects should also be considered.


Introduction
Breast cancer is the most common cancer worldwide that threatens women's health [1]. Meanwhile, the survival rate of breast cancer patients increased significantly, due to a gradual improvement in screening, diagnostic, and therapeutic technology. In the long-term survival process, how to maintain psychosocial well-being of breast cancer patients has become the focus of the nursing staff.
At present, surgery combined with possible radiotherapy and chemotherapy is still the preferred treatment for breast cancer patients. Receiving these treatments is associated with negative body image, such as breast loss, hair loss, and skin damage. These changes and losses in appearance can lead to cognitive, behavioral, and emotional changes, and a perceived loss of femininity and attractiveness, which can affect their self-esteem and quality of life [2][3][4][5], and also it will negatively affect the well-being of couples and lead to sexual disorders [6,7]. Therefore, there is a need to provide support for the appearance-related side effects of treatment to maintain their psychosocial well-being.
The current interventions on appearance-related side effects of breast cancer survivors mainly focus on cognitivebehavioral therapy [8], health education [9], exercise therapy [10,11], support group intervention [12], and marital Mengyao Zhu and Shihao Sun should be considered joint first author. therapy [13]. However, there is no consensus on whether these interventions improve appearance-related side effects, and most psychological interventions do not specifically focus on them, which are often addressed as a small part of larger interventions.
Appearance care is designed to teach makeup techniques and camouflage strategies in response to changes in appearance [14], which act directly on appearance-related side effects. Appearance care is particularly promising as a simple, convenient, and economical method that also does not require technologically advanced equipment. Given the important impact of appearance-related side effect on the psychosocial well-being of patients with breast cancer, increasingly researchers explored the effectiveness on appearance care on psychosocial outcomes. Studies have shown that targeted appearance care for breast cancer patients can effectively reduce body image disturbance [15], improve sexual function [15], self-esteem [14,[16][17][18][19], anxiety and depression [15][16][17][18][19], and quality of life [14,19,20]. However, there are also studies with different results [21,22]. Since the inconsistent results and unknown magnitude of effects, a systematic review of the existing evidence is warranted to enable informed decisions about the clinical implications and further research orientation. Thus, this systematic review and meta-analysis aims to synthesize the evidence for the effects of appearance care on psychosocial outcomes, including but not limited to body image, self-esteem, anxiety, depression, quality of life, and sexual function.

Inclusion and exclusion criteria
Clinical trials (including RCTs and quasi-experimental studies) of breast cancer patients were included. The intervention measures in the intervention group involved appearance care or related interventions. The intervention measures in the possible control groups were usual care or no control. The outcome indicators of each study had psychosocial outcomes, such as body image, self-esteem, depression, anxiety, sexual function, and quality of life. Other exclusion criteria were as follows: reviews, comments, and letters, and no data or incomplete data.

Appraisal of included studies
The JBI Critical Appraisal Checklists for RCTs and for quasi-experimental studies were used to assess the methodological quality of the included studies [23]. The checklist for RCTs includes 13 items and for quasi-experimental studies includes 9 items. Each checklist was rated "Yes," "No," "Unclear," or "Not Applicable." The appraisal process was performed independently by two reviewers. Disagreements were resolved by a discussion with a third reviewer. While there was no consensus on determining the cutoff point for inclusion of papers after methodological evaluation, it was generally accepted that, if included, at least 50% of the evaluation criteria were met [24].

Study selection and data extraction
EndnoteX9 was used to collect and screen literature. First, we removed the duplicate literature retrieved from the four databases. Studies were initially screened by title and abstract. Then, the full text was read to assess eligibility for inclusion. When duplicate articles from the same institution were reported, either the better quality or most recent publication was included. We extracted data and recorded the information: (1) the first author, the year of publication, and the country; (2) study type; (3) study setting; (4) sample size; (5) sample characteristic; (6) intervention type, components, dosage, and mode; (7) facilitators; (8) outcome measures; (9) duration of follow-up; and (10) results. Meanwhile, we extracted data for calculating the effect size. In studies without a control group, the pre-intervention time point was considered a control. The study selection and data extraction process were performed independently by two reviewers. Disagreements were resolved by a discussion with a third reviewer.

Data synthesis
Rev Man 5.4.1 was used for data analysis. If P > 0.1 or I 2 < 50%, multiple studies were considered to be homogenous, and a fixed effect model was used; otherwise, a random effect model was selected. When the results were measured using the same scale or assessment tool, the weighted mean differences (MD) were compared; otherwise, the standardized mean differences (SMD) were compared. The corresponding 95% confidence interval (CI) was calculated. For those studies that did not provide eligible data, descriptive analyses were used. Based on the time point of measurement after the intervention, the immediate post-intervention measurement was referred to as the immediate effect, and the 1-3 months postintervention measurement was referred to as the shortterm effect, in which context a subgroup analysis was applied. Effect sizes were determined according to the Cohen guidelines, with 0.2 considered a small effect; 0.5, moderate; and 0.8, large [25].

Results
As shown in Fig. 1, a systematic search yielded 1930 articles. After removing 485 duplicates, 1445 papers were left for the title and abstract screening, and 1046 records that did not meet the inclusion criteria were further removed. Then, 39 full-text articles were reviewed, and 25 studies that were found not to meet the inclusion criteria were further excluded. Subsequently, 7 studies were rejected due to qualitative studies, the same authorship, or incomplete data, or the population was not breast cancer. Finally, this systematic review included 7 articles, including 2 RCTs and 5 quasiexperimental studies. Two studies [19,20] with incomplete data were descriptive. Reports excluded: Qualitative research (n = 2) Same author (n = 2) Incomplete data (n = 2) Not breast cancer (n = 1) Studies included in review (n = 7)

Participant characteristics
All studies focused on patients during treatment or recovery period. The studies by Ikeda (2020) (31%) [14], Panissi (2021) (16.5%) [16], and Di Mattei (2017) (25%) [17] had a small number of patients who had not undergone surgery. Besides, participants of the remaining study were postsurgical breast cancer patients, including patients who will be having, who are having, or who had completed adjuvant therapy.

Intervention characteristics
The types of interventions were mainly education program. Among them, one study (Kang, 2022) [15] combined psychological intervention, while one study (Quintard, 2008) [21] adopted only cosmetic treatment. The intervention components were mainly to teach makeup techniques and camouflage strategies, including wigs and eyebrows. The number of interventions varied from 1 to 4 times, the duration varied from 1 day to 4 weeks, and the total duration varied from 2 to 16 h. The intervention mode was mainly face-to-face group, while only one study (Quintard, 2008) [21] adopted one-to-one treatment. Interventions were mainly performed by cosmetic specialists, with only two studies (Ikeda, 2020;Kang, 2022) [14,15] involving oncology nurse specialists.

Body image
Body image was evaluated in six studies [15-18, 21, 22] involving 686 participants. Eight instruments were used to measure body image level: the Body-Image Questionnaire; the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Breast cancer module (EORTCQLQ-BR23); the Body Image Scale (Hopwood et al., 2001); the Body Image States Scale; Body Cathexis Scale; Body Image Scale (Leon et al., 1979); Body Parts Satisfaction Scale; and a 10-point scale.
Among the studies, five studies [16-18, 21, 22] assessed the immediate effect of appearance care on body image, and only two studies [17,18] generated a significant result. Five studies were eligible for meta-analysis without showing an overall statistically significant effect on body image (SMD = 0.25, 95% CI − 0.18 to 0.68, P = 0.26, I 2 = 89%).
Among the studies, four studies [14,17,18,22] assessed the immediate effect of appearance care on self-esteem, and only one study [18] generated a significant result. Four studies were eligible for meta-analysis showing an effect of appearance care on self-esteem (MD = 0.63, 95% CI 0.37 to 0.89, P < 0.00001, I 2 = 0%).

Anxiety
Anxiety was evaluated in six studies [15-18, 21, 22] involving 620 participants. Three instruments were used to measure anxiety level: the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory-II, and the Visual Analogue Scale (VAS).

Sexual function
Sexual function was evaluated in 2 studies [15,22] involving 159 participants. Two instruments were used to measure sexual function: the Derogatis Sexual Functioning Inventory and EORTCQLQ-BR23.
Only one study [22] assessed the immediate effect of appearance care on sexual function, showing a significant result. While both two studies [15,22] assessed the shortterm effect of appearance care on sexual function, all generated a significant result. Two studies were eligible for meta-analysis showing a moderate effect of appearance care on sexual function (SMD = 0.50, 95% CI 0.18 to 0.81, P = 0.002, I 2 = 0%) ( Supplementary Fig. 3).

Quality of life
Quality of life was evaluated in 2 studies [14,17] involving 143 participants. Three instruments were used to measure quality of life level: Functional Assessment of Cancer Therapy-General and EORTCQLQ-C30 and Skindex-16.
Among the studies, two studies [14,17] assessed both the immediate and short-term effect of appearance care on quality of life. Two tools of one study [14] generated a significant result on immediate effect, and Skindex-16 of one study [14] generated a significant result on short-term effect. Two studies were eligible for meta-analysis without showing an overall statistically immediate (SMD = 0.82, 95% CI − 0.14 to 1.78, P = 0.10, I 2 = 95%) and short-term (SMD = − 0.08, 95% CI − 1.33 to 1.18, P = 0.91, I 2 = 97%) significant effect on quality of life ( Supplementary Fig. 4).

Other outcomes
Some studies assessed the effect of appearance care on happiness [18], attractiveness [18], social support [22], and coping style [21,22], and the results showed appearance care had a significant short-term effect on happiness and attractiveness, while the immediate and short-term effects of social support and coping style were not significant.

Sensitivity analysis
The included studies were deleted one by one for sensitivity analysis to evaluate the impact of a single study on the combined effect size. The results did not change substantially. That was to say the meta-analysis results were relatively robust.

Publication bias
Given that no pooled analysis combined more than 10 studies, publication bias was not assessed [26].

Critical appraisal result and quality of evidence
All studies scored at least 50% on the JBI checklist and were therefore included in this systematic review. Among the RCTs, the study (Kang, 2022) blinding of intervention practitioners and outcome assessors could not be achieved, and other items were scored as "yes." The study (Quintard, 2008) had five items (1-2, 4-6) that were all scored as "unclear." In quasi-experimental studies (Sharon L, 1994 and Park HY, 2015), all applicable items were scored "yes," three pre-and post-test studies (Panissi KC, 2021; Ikeda M, 2020; Di Mattei VE, 2017) failed to achieve to set up the control group (item 4), and all remaining applicable items were scored "yes." The quality assessment results for the RCTs and the quasi-experimental are presented in Table 2 and Table 3.

Discussion
To the best of our knowledge, this systematic review and meta-analysis is the first to examine the effectiveness of appearance care on psychosocial outcomes of breast cancer patients. The review revealed that there were significant immediate and short-term effects of appearance care on anxiety and depression. Appearance care had beneficial psychological effects on mood [27]. The facilitators taught patients makeup skills to bring their female image closer to their ideal image and increase self-image satisfaction, which led to changes in an emotional state. Plus, what these interventions had in common was that they all allowed participants to practice makeup skills, take photos as souvenirs if necessary, and stimulate a positive emotional response to their makeupbeautiful selves. Except for the study (Quintard, 2008) [21], other studies set up group discussions, sharing experiences, and mutual support with patients who had experienced the same, and could also promote positive emotional changes. Future interventions targeting negative emotions could take into account appearance care programs.
The review also showed that there were significant immediate and short-term effects of appearance care on sexual function. Appearance care can be a necessary first step in resolving intimacy problems. Since body image strongly interfered with sexual function in patients [28], related changes in body image could affect sexual function. During treatment period, the patient perceived a decrease in sexual unattractiveness due to the change in appearance, and appearance care could prompt them to face the change in appearance. However, relevant changes in the body included not only externally visible changes (hair loss, scarring, etc.) but also internal changes (such as perceptions about sex) [29]. It was suggested that sexual function must be considered a variable related to cosmetic care planning evaluation. In addition, patients who felt supported by their spouses had good overall sexual function [28]. It was recommended that spousal-involved psychosexual interventions be introduced appropriately in future appearance care to achieve better results.
The review also showed that there was significant immediate effect of appearance care on self-esteem, without short-term effect. Self-esteem entails individual respect and the value attributed to oneself [22]. When receiving appearance care, patients were given the opportunity to re-examine themselves [14], resulting in an immediate increase in self-esteem. However, self-esteem was considered a personal trait, and after participating in a brief, low-dose appearance management program, patients' compliance with appearance self-management might not be high, thus affecting the long-term effect of the intervention. In the future, we need to take into account monitoring of participants' adherence to appearance management in lieu of simple follow-up. When necessary, digital technology can be used.
However, appearance care had no statistically significant effect on body image, both immediate and short-term effects. Body image is conceptualized as a multifaceted construct, defined as the mental representation of one's body, and feelings about physical appearance and attractiveness, as well as perceived state of overall health and sexuality. Perhaps brief interventions in appearance care may fail to target specific body image-related constructs [30]. Besides, appearance care might confront patients to face changes in appearance in advance, with negative effects on the patient, diminishing the immediate effect of the intervention. The spontaneous adaptation to appearance changes might have attenuated the short-term effects of the intervention on body image. It was also possible that body image issues were not a primary concern for some patients, as patients might be more concerned with survival or the next steps of treatment. Perhaps the timing of the intervention played an important role. Coupled with the large heterogeneity of the studies, the results of the meta-analysis need further verification. However, a metaanalysis by Sebri et al. [29] suggested that psychological interventions are effective in reducing body image issues. Perhaps, the introduction of targeted psychological interventions in appearance care is promising.
Similarly, appearance care had no statistically significant effect on quality of life, both immediate and short-term effects. One possible explanation might be related to that quality of life is not the main objective of interest. Both two studies [14,17] were pre-and post-test studies. Di Mattei (2017) [17] had participants still undergoing chemotherapy,   [14] had participants who will be having, who are having, or who have completed chemotherapy. Chemotherapy can negatively affect the quality of life of breast cancer patients, and patients who have received chemotherapy generally have a poor quality of life [31]. Combined with experiencing a range of cosmetic changes such as hair loss, skin pigmentation, and weight changes, these negative effects on quality of life may undermine the positive effects of appearance care.
Regarding the facilitators, all the studies were led by beauty experts, ignoring the important role of nurses. Qualitative studies [32] have found that the majority of patients categorize appearance care as care services related to their physical and mental state and medical complementary. 8 Was follow-up complete, and if not, were differences between groups in terms of their follow-up adequately described and analyzed? 9 Were participants analyzed in the groups to which they were randomized?
10 Were outcomes measured in the same way for treatment groups?
11 Were outcomes measured in a reliable way?
12 Was the appropriate statistical analysis used?
13 Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?  2 Were the participants included in any comparisons similar?
3 Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?
4 Was there a control group?
5 Were there multiple measurements of the outcome both pre and post the intervention/exposure? 6 Was follow-up complete, and if not, were differences between groups in terms of their follow-up adequately described and analyzed?
7 Were the outcomes of participants included in any comparisons measured in the same way? Almost all patients expected hospital-provided appearance care and hoped that care will continue. Perhaps, in the future, an oncology nurse-led cosmetic care plan could be considered, which may be more beneficial for patients.

Limitations and implications
We acknowledge several limitations of this review. First, appearance care for breast cancer patients is still in its infancy. The dose and frequency of interventions are less frequent, and the number of available studies is very small. Second, the heterogeneity is very large, such as methodological heterogeneity (including non-randomized controlled trials) and non-uniform measurement tools. Finally, assessments of the long-term effects of appearance interventions are limited due to a general lack of methodological rigor. Despite these limitations, future work may benefit from this review. It is worthwhile to develop digitally assisted RCTs with a large sample, and it is necessary to monitor compliance with appearance management online and explore long-term effects. We should also focus on qualitative data on patients' subjective experiences to explore personalized interventions and make improvements.

Conclusion
Appearance care may be a promising intervention to improve anxiety, depression, self-esteem, and sexual dysfunction in breast cancer patients. However, improvements in body image and quality of life have not been found. More highquality RCTs are needed to validate these findings. Online appearance care programs and exploration of long-term effects should also be considered.