Beyond Scars: Development and Validation of a Four-Dimensional Body Image Score for Women with Breast and Gynecological Cancers - A Tunisian Multicenter Study

Abstract

Background: Body image disturbances in breast and gynecological cancer survivors involve complex interrelationships between physical changes, sexuality, and self-esteem. Existing tools inadequately capture these multidimensional, cancer-specific concerns. This study developed and validated a Four-Dimensional Body Image Score for women with breast and gynecological Cancers (4D-BISC). Methods: A cross-sectional study was conducted (March-April 2025) across six Tunisian healthcare facilities. Women presenting with gynecological or breast cancers were included. Participants completed the 16-item questionnaire (5-point Likert scale) derived from validated scales (the Female Sexual Function Index (FSFI) and the Body Esteem Scale for Adolescents and Adults (BESAA)) and cancer-specific items. Psychometric properties were assessed via exploratory/confirmatory factor analyses (EFA/CFA), Cronbach's alpha (α), and correlations with established scales (FSFI, BESAA). Results: In total, 101 participants were included. CFA confirmed a robust 4-factor structure: Appearance Concerns (α=0.704), Social Exposure (α=0.737), Sexual Desirability (α=0.918) and Self-Esteem (α=0.786). The global score demonstrated excellent reliability. Strong correlations emerged between body image factors and sexual function (e.g., Sexual Desirability and sexual desire: p=0.706 and p<0.001 respectively). Breast cancer patients reported significantly worse body image globally (p=0.003), particularly in social exposure (median=26.7) and sexual desirability (median=30). Marital status and socioeconomic status significantly influenced sexuality-related concerns and self-esteem (p<0.05). Conclusion: The 4D-BISC is a psychometrically valid tool capturing cancer-specific body image dimensions. It highlights critical vulnerabilities among breast and gynecological cancers cancer patients- and provides a foundation for targeted psychosocial interventions.