In China, breast cancer is the most common cancer diagnosed among women, and it is the fourth in cancer death in women . Breast cancer surgery and adjuvant therapies can result in loss of a breast, scarring, alopecia, and skin alterations as well as weight changes. These physical appearance changes, together with various symptoms such as sensation alteration, arm function impairment, and fatigue can change breast cancer survivors’ mental image of their bodies [2-4]. Body image encompasses one’s body-related self-perceptions, attitudes, and behaviors , and body image concerns are one of the most common psychosocial issues experienced by breast cancer survivors. Poor body image has been linked to depression [6,7], sexual concerns [8,9], and psychological distress in breast cancer survivors [3,10].
Helping breast cancer patients adapt to aesthetic and functional changes resulting from the disease and its treatment, whether temporary or permanent, has the potential to reduce body image-related distress and thus improve patients’ quality of life (QoL) as they transition into survivorship [11,12]. Thus, the nature of the relationships between major domains of body image and different domains of QoL need to be understood, as different aspects of body image may play different roles in influencing survivors’ QoL . Researchers have reported that overall body image was correlated with QoL in breast cancer survivors [7,13], but few have explored the relationship between the various body image and QoL domains. Moreover, few findings regarding the relationship have been reported for Chinese breast cancer survivors, who are more likely to be diagnosed before the age of 50 years and have more advanced staging than western women [14,15]. They also tend to undergo more aggressive treatments and are less likely to have breast reconstruction; a stable low reconstruction rate at about 3.5% was observed among Chinese breast cancer survivors [15,16]. The reasons for the low reconstruction rate were reported to be smaller breast volume of Chinese women, patients’ traditional beliefs that cancers should be radically resected, their lack of awareness of the possibility of breast reconstruction, shortage of radiation therapy and skilled surgeons, and lack of insurance coverage [16,17].
In addition, little research attention has been given to body image among rural breast cancer survivors. In China, rural breast cancer survivors tend to exhibit more progressive breast cancer than urban survivors . This leads to a higher proportion of modified radical mastectomies and more adjuvant treatments in rural women with breast cancer, which can greatly influence their body image and QoL [18,19]. The relationship between body image and QoL also likely differs due to various determinants of rural-urban disparities . However, it appears that no previous research has examined rural-urban residence as a moderator of the relationship between body image and QoL in breast cancer survivors. Understanding the role of place of residence may support strategic design of care plans for breast cancer survivors in urban and rural settings. In this study, we aim to investigate the associations between the multiple domains of body image and QoL in Chinese breast cancer survivors and to test whether place of residence has a moderation effect on the associations.
The conceptual framework for this study (Figure 1) was derived from a literature review of the two concepts of interest— QoL [21,22] and body image [23,5]— and the theoretical frameworks addressing relationships between body image and QoL in the contexts of medical conditions  and breast reconstruction . Body image is here defined as a multifaceted construct that refers to the individual’s mental image of her body, which extends beyond the perception of her appearance and involves adaptations to her changing body [11,4]. The body image-related changes are not static; they are experiences of the moment, influenced by the individual’s dynamic adaptation to the disease and its treatment . Thus, the concept of body image does not only address how a woman views her appearance and femininity, but also encompasses body image-related changes in her roles (in conducting daily activities and functioning as a mother and worker), changes in social involvement, changes in behaviors (such as avoiding attention to her body and repeatedly checking her breast), and sexual functioning changes (such as decreased sexual desire and arousal) . Similar to body image, QoL is recognized to be multidimensional in nature and entirely subjective [24,25]. In this study, we focus on two major QoL domains that body image may affect: physical and mental well-being. Physical well-being encompasses one’s perceived physical function, bodily pain, and role limitations due to physical problems [26,22]. Mental well-being mainly involves social functioning, emotional and mental health, and role limitations due to emotional problems [25,26,22].
According to Pruzinsky , body image related changes can be pervasive and strong enough to impact QoL in populations with medical conditions. We posit that different domains of body image-related changes are correlated with mental and physical well-being in breast cancer survivors. The constructs of body image and QoL affect each other and overlap from a conceptual standpoint, but each has unique features . Our theoretical framework suggests that body image may both influence and be influenced by QoL. Based on the literature, other factors also influence breast cancer survivors’ body image and QoL. One broad category is premorbid influences, which refer to past experience and one’s position in society [11,19]. This category encompasses socioeconomic status, place of residence, access to healthcare services, social culture, and psychological factors. The other category is the breast cancer disease and its treatment factors, which include clinical stage, surgery type, post-surgery time, adjuvant therapy, and post-surgery time [11,2,19]. In this study, we define the place of residence in terms of self-identification because this is especially useful when focusing on individual subjective experience such as body image and QoL, which is influenced by self-identity as well as cultural perceptions.
Based on our conceptual framework, this study aimed to (1) examine the associations between body image and QoL subdomains in Chinese breast cancer survivors and (2) test whether the associations between body image and QoL are moderated by place of residence. The findings of this investigation will enhance the understanding of rural-urban disparities in psychosocial health and shed light on the development of evidence-based clinical practice and survivorship care to address the body image concerns of the growing population of breast cancer survivors and improve their overall QoL.