Supportive Care in Cancer

, Volume 27, Issue 10, pp 3657–3666 | Cite as

A systematic review of body image measures for people diagnosed with head and neck cancer (HNC)

  • Chindhu Shunmuga Sundaram
  • Haryana M. Dhillon
  • Phyllis N. Butow
  • Puma Sundaresan
  • Claudia RutherfordEmail author
Review Article



Head and neck cancer (HNC) is a relatively common cancer which causes a significant health burden, impacting individuals physically and psychologically. HNC treatment may result in facial disfigurement, eating and communication difficulties, and body image disturbances. We aimed to (1) identify HNC-specific patient-reported outcome measures (PROMs) used to assess body image, (2) evaluate their conceptual coverage, (3) appraise their development process and psychometric properties, and (4) determine appropriate body image PROM(s) for use in the HNC setting.


Online databases were searched (July 2007–July 2017) for studies that assessed body image in patients with HNC. Studies were screened for eligibility. In addition, we searched three PROM databases for relevant PROMs. From available body image frameworks, we compiled a conceptual schema consisting of 18 clinically relevant body image issues important in the HNC setting, against which PROMs were assessed. Selected measures were appraised for psychometric characteristics, content, and readability.


A total of 245 records were retrieved. 18 studies with PROMs met our inclusion criteria, reporting eight PROMs. The PROM databases searched yielded 62 measures. After screening, eleven measures were short-listed and appraised. The Derriford Appearance Scale (DAS)-59, DAS-24, and body image scale (BIS) cover > 55% of issues within the body image conceptual schema; were developed based on literature, patient interviews, and clinician opinions; and have evidence of internal consistency (Cronbach alpha > 0.7), validity, and responsiveness.


We recommend the DAS-24 and BIS as having adequate coverage of HNC-related issues, and suitable for use in future research.


Head and neck cancer Body image Patient-reported outcome measures Validation Content validity Systematic review 



We thank Rhiannon Ashleigh for her assistance with data extraction.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

520_2019_4919_MOESM1_ESM.docx (16 kb)
ESM 1 (DOCX 16 kb)


  1. 1.
    Joshi P, Dutta S, Chaturvedi P, Nair S (2014) Head and neck cancers in developing countries. Rambam Maimonides Med J 5(2):e0009Google Scholar
  2. 2.
    Mehanna H, Paleri V, West CML, Nutting C (2010) Head and neck cancer—part 1: epidemiology, presentation, and prevention. Bmj 341:c4684Google Scholar
  3. 3.
    Simard EP, Torre LA, Jemal A (2014) International trends in head and neck cancer incidence rates: differences by country, sex and anatomic site. Oral Oncol 50(5):387–403Google Scholar
  4. 4.
    Das R et al (2017) A study of head and neck cancer patients with special reference to tobacco use and educational level. Clin Cancer Investig J 6(1):21Google Scholar
  5. 5.
    Lambert R, Sauvaget C, de Camargo Cancela M, Sankaranarayanan R (2011) Epidemiology of cancer from the oral cavity and oropharynx. Eur J Gastroenterol Hepatol 23(8):633–641Google Scholar
  6. 6.
    Gupta B, Johnson NW, Kumar N (2016) Global epidemiology of head and neck cancers: a continuing challenge. Oncology 91(1):13–23Google Scholar
  7. 7.
    Hopwood P, Fletcher I, Lee A, al Ghazal S (2001) A body image scale for use with cancer patients. Eur J Cancer 37(2):189–197Google Scholar
  8. 8.
    Ojo B, Genden EM, Teng MS, Milbury K, Misiukiewicz KJ, Badr H (2012) A systematic review of head and neck cancer quality of life assessment instruments. Oral Oncol 48(10):923–937Google Scholar
  9. 9.
    Callahan C (2005) Facial disfigurement and sense of self in head and neck cancer. Soc Work Health Care 40(2):73–87Google Scholar
  10. 10.
    Kent G (2000) Understanding the experiences of people with disfigurements: an integration of four models of social and psychological functioning. Psychol Health Med 5(2):117–129Google Scholar
  11. 11.
    Rumsey N, Clarke A, White P, Wyn-Williams M, Garlick W (2004) Altered body image: appearance-related concerns of people with visible disfigurement. J Adv Nurs 48(5):443–453Google Scholar
  12. 12.
    Clarke S-A, Newell R, Thompson A, Harcourt D, Lindenmeyer A (2014) Appearance concerns and psychosocial adjustment following head and neck cancer: a cross-sectional study and nine-month follow-up. Psychol Health Med 19(5):505–518Google Scholar
  13. 13.
    Rhoten BA, Murphy B, Ridner SH (2013) Body image in patients with head and neck cancer: a review of the literature. Oral Oncol 49(8):753–760Google Scholar
  14. 14.
    Rhoten BA (2016) Body image disturbance in adults treated for cancer–a concept analysis. J Adv Nurs 72(5):1001–1011Google Scholar
  15. 15.
    Yam, M., Does culture matter in body image? The effects of subjective and contextual culture on body image among bicultural women. 2013Google Scholar
  16. 16.
    Cash TF (2012) Cognitive-behavioral perspectives on body image. In: Encyclopedia of body image and human appearance. Elsevier, pp 334–342Google Scholar
  17. 17.
    Moorey S (2007) Breast cancer and body image. The female body in mind: the Interface between the female body and mental health, p 72Google Scholar
  18. 18.
    White CA (2000) Body image dimensions and cancer: a heuristic cognitive behavioural model. Psycho-Oncology 9(3):183–192Google Scholar
  19. 19.
    Muzzatti B, Annunziata MA (2017) Body image assessment in oncology: an update review. Support Care Cancer 25(3):1019–1029Google Scholar
  20. 20.
    Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ (2000) Reliability and validity of an observer-rated disfigurement scale for head and neck cancer patients. Head Neck 22(2):132–141Google Scholar
  21. 21.
    Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ (2003) Psychosocial adjustment in head and neck cancer: the impact of disfigurement, gender and social support. Head Neck 25(2):103–112Google Scholar
  22. 22.
    Booth, A., et al., PROSPERO: an international prospective register of systematic reviewsGoogle Scholar
  23. 23.
    Booth A, Clarke M, Dooley G, Ghersi D, Moher D, Petticrew M, Stewart L (2012) The nuts and bolts of PROSPERO: an international prospective register of systematic reviews. Syst Rev 1(1):2Google Scholar
  24. 24.
    Vega-Vázquez MA, Gonzalez-Rodriguez L, Santiago-Rodríguez EJ, Garcés-Domínguez A, Shum LM, Tírado-Gómez M, Ramírez-Vick M (2015) Quality of LIFE in patients with differentiated thyroid cancer at the general endocrinology clinics of the UNIVERSITY hospital of Puerto Rico. Boletin de la Asociacion Medica de Puerto Rico 107(1):25–31Google Scholar
  25. 25.
    Chua AS, DeSantis SM, Teo I, Fingeret MC (2015) Body image investment in breast cancer patients undergoing reconstruction: taking a closer look at the appearance schemas inventory-revised. Body Image 13:33–37Google Scholar
  26. 26.
    Moorey S (2007) Breast cancer and body image. In: The Female Body in Mind. Routledge, pp 88–106Google Scholar
  27. 27.
    Moreira H, Canavarro MC (2010) A longitudinal study about the body image and psychosocial adjustment of breast cancer patients during the course of the disease. Eur J Oncol Nurs 14(4):263–270Google Scholar
  28. 28.
    Dropkin MJ (1989) Coping with disfigurement and dysfunction after head and neck cancer surgery: a conceptual framework. In: Seminars in oncology nursing. ElsevierGoogle Scholar
  29. 29.
    Newell R (2002) The fear-avoidance model: helping patients to cope with disfigurement. Nurs Times 98(16):38–39Google Scholar
  30. 30.
    Newell RJ (1999) Altered body image: a fear-avoidance model of psycho-social difficulties following disfigurement. J Adv Nurs 30(5):1230–1238Google Scholar
  31. 31.
    Cash, T.F., Cognitive-behavioral perspectives on body image. 2011Google Scholar
  32. 32.
    Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, Bouter LM, de Vet HCW (2010) The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res 19(4):539–549Google Scholar
  33. 33.
    Embretson SE, Reise SP (2013) Item response theory. Psychology PressGoogle Scholar
  34. 34.
    Fan X (1998) Item response theory and classical test theory: an empirical comparison of their item/person statistics. Educ Psychol Meas 58(3):357–381Google Scholar
  35. 35.
    Kean J, Reilly J (2014) Item response theory. In: Handbook for clinical research: design, statistics and implementation. Demos Medical Publishing, New York, NY, pp 195–198Google Scholar
  36. 36.
    Rasch G A mathematical theory of objectivity and its consequences for model construction. In: European meeting on statistics. Econometrics and Management Science, Amsterdam, p 1968Google Scholar
  37. 37.
    Ley P, Florio T (1996) The use of readability formulas in health care. Psychol Health Med 1(1):7–28Google Scholar
  38. 38. Tests Document Readability. 2009 [cited 2018 18 April]; Available from:
  39. 39.
    Cash TF, Labarge AS (1996) Development of the appearance schemas inventory: a new cognitive body-image assessment. Cogn Ther Res 20(1):37–50Google Scholar
  40. 40.
    Cash TF, Melnyk SE, Hrabosky JI (2004) The assessment of body image investment: an extensive revision of the appearance schemas inventory. Int J Eat Disord 35(3):305–316Google Scholar
  41. 41.
    Cash TF, Santos MT, Williams EF (2005) Coping with body-image threats and challenges: validation of the body image coping strategies inventory. J Psychosom Res 58(2):190–199Google Scholar
  42. 42.
    Brown TA, Cash TF, Mikulka PJ (1990) Attitudinal body-image assessment: factor analysis of the body-self relations questionnaire. J Pers Assess 55(1–2):135–144Google Scholar
  43. 43.
    Cash TF (2015) Multidimensional Body–Self Relations Questionnaire (MBSRQ). In: Encyclopedia of Feeding and Eating Disorders. Springer, pp 1–4Google Scholar
  44. 44.
    Cash TF, Fleming EC (2002) The impact of body image experiences: development of the body image quality of life inventory. Int J Eat Disord 31(4):455–460Google Scholar
  45. 45.
    Cash TF, Jakatdar TA, Williams EF (2004) The body image quality of life inventory: further validation with college men and women. Body Image 1(3):279–287Google Scholar
  46. 46.
    Albani C et al (2006) Überprüfung und Normierung des" Fragebogen zum Körperbild"(FKB-20) von Clement und Löwe (1996) an einer repräsentativen deutschen Bevölkerungsstichprobe. Z Med Psychol 15(3):99–109Google Scholar
  47. 47.
    Clement U, Löwe B (1996) Validation of the FKB-20 as scale for the detection of body image distortions in psychosomatic patients. Psychother Psychosom Med Psychol 46(7):254–259Google Scholar
  48. 48.
    Klassen AF, Cano SJ, Scott A, Johnson J, Pusic AL (2012) Satisfaction and quality-of-life issues in body contouring surgery patients: a qualitative study. Obes Surg 22(10):1527–1534Google Scholar
  49. 49.
    Klassen AF et al (2016) The BODY-Q: a patient-reported outcome instrument for weight loss and body contouring treatments. Plast Reconstr Surg Glob Open 4:4Google Scholar
  50. 50.
    Carr T, Harris D, James C (2000) The Derriford appearance scale (DAS-59): a new scale to measure individual responses to living with problems of appearance. Br J Health Psychol 5(2):201–215Google Scholar
  51. 51.
    Harris DL, Carr AT (2001) The Derriford appearance scale (DAS59): a new psychometric scale for the evaluation of patients with disfigurements and aesthetic problems of appearance. Br J Plast Surg 54(3):216–222Google Scholar
  52. 52.
    Harris DL (1982) The symptomatology of abnormal appearance: an anecdotal survey. Br J Plast Surg 35(3):312–323Google Scholar
  53. 53.
    Cogliandro A, Persichetti P, Ghilardi G, Moss TP, Barone M, Piccinocchi G, Ricci G, Vitali M, Giuliani A, Tambone V (2016) How to assess appearance distress and motivation in plastic surgery candidates: Italian validation of Derriford appearance scale 59 (DAS 59). Eur Rev Med Pharmacol Sci 20(18):3732–3737Google Scholar
  54. 54.
    Nozawa K et al (2008) Development of the Japanese version of Derriford appearance scale DAS59: a QOL index for the people who have problems of appearance. J Jpn Soc Plast Reconstr Surg 28(7):440–448Google Scholar
  55. 55.
    Singh VP, Singh RK, Moss TP, Roy DK, Baral DD (2013) Translation and validation of the Nepalese version of Derriford appearance scale (DAS-59). Modern Plast Surg 3(2):51–56Google Scholar
  56. 56.
    Herruer J et al (2018) Does self-consciousness of appearance influence postoperative satisfaction in rhinoplasty? J Plast Reconstr Aesthet Surg 71(1):79–84Google Scholar
  57. 57.
    Moss TP, Lawson V, Liu CY (2015) The Taiwanese Derriford appearance scale: the translation and validation of a scale to measure individual responses to living with problems of appearance. PsyCh J 4(3):138–145Google Scholar
  58. 58.
    Moss TP, Cogliandro A, Pennacchini M, Tambone V, Persichetti P (2013) Appearance distress and dysfunction in the elderly: international contrasts across Italy and the UK using DAS59. Aesthet Plast Surg 37(6):1187–1193Google Scholar
  59. 59.
    Carr T, Moss T, Harris D (2005) The DAS24: a short form of the Derriford appearance scale DAS59 to measure individual responses to living with problems of appearance. Br J Health Psychol 10(2):285–298Google Scholar
  60. 60.
    Merz EL et al (2018) Factor structure and convergent validity of the Derriford appearance Scale-24 using standard scoring versus treating ‘not applicable’responses as missing data: a scleroderma patient-centered intervention network (SPIN) cohort study. BMJ Open 8(3):e018641Google Scholar
  61. 61.
    Moss TP, Lawson V, White P (2015) Identification of the underlying factor structure of the Derriford appearance scale 24. PeerJ 3:e1070Google Scholar
  62. 62.
    Melissant HC et al (2018) A systematic review of the measurement properties of the body image scale (BIS) in cancer patients. Support Care Cancer:1–12Google Scholar
  63. 63.
    Sprangers M et al (1996) The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study. J Clin Oncol 14(10):2756–2768Google Scholar
  64. 64.
    Brédart A, Verdier AS, Dolbeault S (2007) Traduction/adaptation française de l’échelle “Body Image Scale”(BIS) évaluant la perception de l’image du corps chez des femmes atteintes de cancer du sein. Psycho-oncologie 1(1):24–30Google Scholar
  65. 65.
    Gómez-Campelo P, Bragado-Álvarez C, Hernández-Lloreda MJ, Sánchez-Bernardos ML (2015) The Spanish version of the body image scale (S-BIS): psychometric properties in a sample of breast and gynaecological cancer patients. Support Care Cancer 23(2):473–481Google Scholar
  66. 66.
    Moreira H, Silva S, Marques A, Canavarro MC (2010) The Portuguese version of the body image scale (BIS)–psychometric properties in a sample of breast cancer patients. Eur J Oncol Nurs 14(2):111–118Google Scholar
  67. 67.
    Khang D, Rim H-D, Woo J (2013) The Korean version of the body image scale-reliability and validity in a sample of breast cancer patients. Psychiatry Investig 10(1):26–33Google Scholar
  68. 68.
    Anagnostopoulos F, Myrgianni S (2009) Body image of Greek breast cancer patients treated with mastectomy or breast conserving surgery. J Clin Psychol Med Settings 16(4):311–321Google Scholar
  69. 69.
    Brédart A, Dolbeault S, Savignoni A, Besancenet C, This P, Giami A, Michaels S, Flahault C, Falcou MC, Asselain B, Copel L (2011) Prevalence and associated factors of sexual problems after early-stage breast cancer treatment: results of a French exploratory survey. Psycho-Oncology 20(8):841–850Google Scholar
  70. 70.
    Sbitti Y, Kadiri H, Essaidi I, Fadoukhair Z, Kharmoun S, Slimani K, Ismaili N, Ichou M, Errihani H (2011) Breast cancer treatment and sexual dysfunction: Moroccan women’s perception. BMC Womens Health 11(1):29Google Scholar
  71. 71.
    Helms RL, O'Hea EL, Corso M (2008) Body image issues in women with breast cancer. Psychol Health Med 13(3):313–325Google Scholar
  72. 72.
    Nayak SG, Pai MS, George LS (2016) Self-image of the patients with head and neck cancer: a mixed method research. Indian J Palliat Care 22(3):331Google Scholar
  73. 73.
    Polit DF, Beck CT (2006) The content validity index: are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 29(5):489–497Google Scholar
  74. 74.
    Polit DF, Beck CT (2010) Essentials of nursing research: appraising evidence for nursing practice. Lippincott Williams & WilkinsGoogle Scholar
  75. 75.
    Polit DF, Beck CT (2010) Generalization in quantitative and qualitative research: myths and strategies. Int J Nurs Stud 47(11):1451–1458Google Scholar
  76. 76.
    Polit DF, Beck CT, Owen SV (2007) Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health 30(4):459–467Google Scholar
  77. 77.
    Fingeret MC, Nipomnick S, Guindani M, Baumann D, Hanasono M, Crosby M (2014) Body image screening for cancer patients undergoing reconstructive surgery. Psycho-Oncology 23(8):898–905Google Scholar
  78. 78.
    Pusic A et al (2007) A systematic review of patient-reported outcome measures in head and neck cancer surgery. SAGE Publications Sage CA, Los Angeles, CAGoogle Scholar
  79. 79.
    Jabbour J et al (2017) Education and support needs in patients with head and neck cancer: a multi-institutional survey. Cancer 123(11):1949–1957Google Scholar
  80. 80.
    Dropkin MJ (1999) Body image and quality of life after head and neck cancer surgery. Cancer Pract 7(6):309–313Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Centre for Medical Psychology and Evidence-based Decision-making, School of Psychology, Faculty of ScienceUniversity of SydneySydneyAustralia
  2. 2.Psycho-Oncology Cooperative Research GroupUniversity of SydneySydneyAustralia
  3. 3.Radiation Oncology NetworkWestern Sydney Local Health DistrictSydneyAustralia
  4. 4.Sydney Medical SchoolUniversity of SydneySydneyAustralia
  5. 5.Quality of Life Office, School of Psychology, Faculty of ScienceUniversity of SydneySydneyAustralia
  6. 6.Sydney Nursing School, Cancer Nursing Research Unit (CNRU)University of SydneySydneyAustralia

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