Psychological state and body image disturbance in head and neck cancer patients: Prevalence and determinants

Abstract

BACKGROUND

Head and neck cancer (HNC) usually imposes a psychological burden on patients. In particular, treatment-related facial changes often predispose them to body image disturbance (BID), thereby exacerbating psychological stress.

AIM

To characterize the psychological state (anxiety, depression) and BID status in patients with HNC and to identify determinants associated with BID.

METHODS

A total of 100 patients with HNC treated between January 2020 and January 2025 were analyzed. The psychological state was assessed using the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and Hospital Anxiety and Depression Scale-Depression (HADS-D) subscales, while body image-related distress was evaluated using the Body Image Scale (BIS). Linear associations among scales were examined using Pearson’s or Spearman’s correlation coefficients. Potential predictors of BID were evaluated using univariate and multivariable regression models.

RESULTS

Anxiety and depressive symptoms were identified in 25% and 30% of patients, respectively. Mean HADS-A and HADS-D scores were (5.62 ± 2.89) and 5.00 (3.00, 8.00), respectively, while the BIS total score was 16.00 (14.00, 18.00). Global BIS scores and all BIS domains (affective, cognitive, and behavioral) correlated positively with both HADS-A and HADS-D scores. Regression analyses identified multimodal treatment [odds ratio (OR) = 6.730, P = 0.011], female sex (OR = 5.206, P = 0.003), disease progression (OR = 4.316, P = 0.012), unemployment (OR = 3.461, P = 0.042), anxiety (HADS-A; OR = 4.031, P = 0.036), and depression (HADS-D; OR = 3.690, P = 0.039).

CONCLUSION

Patients with HNC commonly present with mild psychological issues accompanied by moderate BID. Female patients, those with late-stage cancer (III-IV), recipients of multimodal therapy, unemployed individuals, and patients with anxiety or depressive symptoms are at greater risk of BID.

Key Words: Head and neck cancer; Psychological state; Body image disturbance; Determinants; Hospital Anxiety and Depression Scale

Core Tip: This study assessed the psychological state and body image disturbance (BID) in patients with head and neck cancer and examined associated determinants. Among 100 head and neck cancer patients, mild psychological distress and moderate BID were observed. Female sex, stage III-IV disease, multimodal therapy, unemployment, and coexisting anxiety or depression were associated with a higher risk of BID, with female sex and multimodal therapy exerting the most significant effects.

INTRODUCTION

Head and neck cancers (HNCs) comprise malignancies of the oral cavity, pharynx, larynx, nasal and paranasal cavities, and salivary glands. Chronic trauma, oral inflammation, and disruptions in microbial balance have been identified as potential triggers[1,2]. Squamous cell carcinoma accounts for approximately 90% of HNC cases, making HNC the seventh most prevalent cancer worldwide; in 2020 alone, approximately one million new cases were reported. Men are disproportionately affected[3,4]. Patients with HNC often experience symptoms such as hoarseness, otalgia, mucosal dysplasia or ulceration, and oral or pharyngeal soreness. Moreover, invasive therapeutic procedures result in body image-related changes of varying severity, including facial asymmetry, impaired muscle motility, and scarring, affecting up to 89% of patients[5,6]. Given the face’s prominence and social salience, such individuals are particularly susceptible to body image disturbance (BID)[7]. BID is characterized by negative cognitions, unpleasant emotions, and stress-related behaviors arising from changes in body structure or functional limitations[8]. HNC-affected individuals frequently experience substantial psychosocial morbidity. Physiological (treatment- and disease-related discomfort), psychological (distress related to altered appearance), and social (withdrawal and isolation) factors collectively increase vulnerability to anxiety, depression, and shame[9]. Previous research have reported mood disorder prevalence rates exceeding 25% among patients with HNC, along with suicide rates threefold higher than those of the general population[10]. Accordingly, early recognition of psychological distress and timely supportive interventions are essential.

At present, evidence regarding the psychological state and BID status of patients with HNC, as well as BID-associated determinants, remains limited. Therefore, the present study examined the relationships between psychological state and BID in patients with HNC and identified key determinants of BID to inform targeted psychological interventions.

MATERIALS AND METHODS

General data

A total of 100 patients with HNC admitted between January 2020 and January 2025 were enrolled. Inclusion criteria were as follows: Pathologically confirmed HNC[11]; age ≥ 18 years; American Joint Committee on Cancer-defined stage I-IV malignancy[12]; intact cognitive function and communication ability; and complete medical records. Exclusion criteria included major trauma within the previous six months; prior head or neck surgery or scarring; severe comorbid physical illness; congenital facial malformations or significant physical dysfunction; and terminal or other life-threatening conditions. The patient selection process is shown in Figure 1.

Figure 1  Patient selection process.

Power calculation

Sample size estimation was performed using Kendall’s rough method[13], based on the recommendation of enrolling 5-10 participants per independent variable. With eight predictors, the initial estimated sample size was 40-80 patients. Allowing for a potential 20% attrition rate, a sample size of 50-100 patients was required; ultimately, 100 patients were included.

Data acquisition and quality control

Eligible patients were identified and recruited by two trained nursing graduates through screening in outpatient clinics and inpatient wards according to the aforementioned selection criteria. Data were collected through one-to-one questionnaire administration. After standardized instructions were provided, participants completed the questionnaires independently, with assistance offered when needed. Disease-related data were extracted from the hospital’s electronic medical record system. All questionnaires were reviewed immediately after collection, and those with > 10% missing data or patterned responses were excluded. Data entry was performed following double verification to ensure accuracy.

Endpoints

Psychological state assessments. The Hospital Anxiety and Depression Scale (HADS)[14] was used to evaluate pretreatment anxiety (HADS-A, 7 items) and depression (HADS-D, 7 items). Total scores were categorized as none (0-7), mild (8-10), moderate (11-14), or severe (15-21). The scale demonstrated high internal consistency, with Cronbach’s α values of 0.806 for total HADS, 0.806 for HADS-A, and 0.80 for HADS-D.

BID evaluation. Posttreatment body image dissatisfaction was assessed using the 10-item Body Image Scale (BIS)[15]. Total scores range from 0 to 30 and are derived from affective, cognitive, and behavioral subscales rated from 0 (“not at all”) to 3 (“extremely”). Higher scores indicate greater symptom severity and distress; a BIS score ≥ 10 indicates BID. The BIS showed excellent reliability (Cronbach’s α = 0.93).

Statistical analysis

Following Excel-based dual-entry data collection, analyses were conducted using SPSS 25.0. Categorical variables are presented n (%). Continuous variables that follow normal or approximately normal distributions are reported as mean ± SD. Group comparisons employed χ² tests for categorical data and Student’s t-tests for continuous variables. Continuous data that violate a normal distribution are expressed by the median (interquartile range) [median, (Q1, Q3)]. Pearson’s or Spearman’s correlation coefficients were used to assess associations among HADS-A, HADS-D, and BIS scores. Potential predictors of BID were examined using univariate analyses followed by multivariate logistic regression. Statistical significance was set at α = 0.05.

RESULTS

Prevalence of psychological distress in patients with HNC

Based on HADS-A and HADS-D assessments of 100 patients with HNC (Tables 1 and 2), the mean HADS-A score was 5.62 ± 2.89, with 25% of patients exhibiting anxiety, predominantly of mild severity. The mean HADS-D score was 5.00 (3.00, 8.00), and 30% of patients met criteria for depression, again mainly mild in severity.

Table 1 Assessment of anxiety disorders in head and neck cancer patients.

HADS-A (points)	Anxiety degree	n (%)
0-7	Normal	75 (75.00)
8-10	Mild	19 (19.00)
11-14	Moderate	6 (6.00)
15-21	Severe	0 (0.00)
Total	5.62 ± 2.89

HADS-A: Hospital Anxiety and Depression Scale-Anxiety.

Table 2 Measurement of depressive conditions in head and neck cancer patients.

HADS-D (points)	Degree of depression	n (%)
0-7	Normal	70 (70.00)
8-10	Mild	24 (24.00)
11-14	Moderate	5 (5.00)
15-21	Severe	1 (1.00)
Total	5.00 (3.00, 8.00)

HADS-D: Hospital Anxiety and Depression Scale-Depression.

Prevalence of BID in patients with HNC

BID, assessed using the BIS (Table 3), yielded a mean total score of 16.00 (14.00, 18.00). Mean subscale scores were 6.44 ± 2.32 for the affective domain, 7.00 (5.00, 8.00) for the cognitive domain, and 3.00 (2.00, 4.00) for the behavioral domain, indicating predominantly moderate BID among participants.

Table 3 Assessment of body image disturbance in head and neck cancer cases.

BIS (points)	Scoring range	Score
Affective	0-12	6.44 ± 2.32
Cognitive	0-12	7.00 (5.00, 8.00)
Behavioral	0-6	3.00 (2.00, 4.00)
Global	0-30	16.00 (14.00, 18.00)
Mild distress	0-10	1 (1.00)
Moderate distress	11-20	90 (90.00)
Severe distress	21-30	9 (9.00)

BIS: Body Image Scale.

Correlation between psychological distress and BID in patients with HNC

Pearson/Spearman correlation analysis (Table 4) demonstrated significant positive associations between psychological distress and BID. Higher HADS-A correlated with affective (r = 0.206, P = 0.040), cognitive (r = 0.445, P < 0.001), behavioral (r = 0.364, P = < 0.001), and global BIS scores (r = 0.308, P = 0.002). Similarly, HADS-D scores were positively associated with affective (r = 0.370, P < 0.001), cognitive (r = 0.344, P < 0.001), behavioral (r = 0.418, P < 0.001), and global BIS (r = 0.388, P < 0.001).

Table 4 Association between anxiety/depressive symptoms and body image distress in head and neck cancer patients.

Correlation analysis	HADS-A (points)	HADS-D (points)
Affective (points)	r = 0.206, P = 0.040	r = 0.370, P < 0.001
Cognitive (points)	r = 0.445, P < 0.001	r = 0.344, P < 0.001
Behavioral (points)	r = 0.364, P < 0.001	r = 0.418, P < 0.001
Global BIS score (points)	r = 0.308, P = 0.002	r = 0.388, P < 0.001

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; BIS: Body Image Scale.

Determinants of BID in patients with HNC

Univariate (Table 5) and multivariate (Table 6) analyses identified key factors associated with BID in HNC patients. No significant relationships were observed for age, educational attainment, or primary tumor site (P > 0.05). In contrast, sex, tumor stage, multimodal treatment history, unemployment, and HADS-A/HADS-D scores were significantly associated with BID (P < 0.05). Multivariate logistic regression further showed that female sex [odds ratio (OR) = 5.206, P = 0.003], advanced disease stage (OR = 4.316, P = 0.012), multimodal treatment history (OR = 6.730, P = 0.011), unemployment (OR = 3.461, P = 0.042), anxiety (HADS-A; OR = 4.031, P = 0.036), and depression (HADS-D; OR = 3.690, P = 0.039) were independent predictors of BID in patients with HNC (all P < 0.05).

Table 5 Univariate evaluation of body image disturbance in head and neck cancer patients.

Variable	BIS < 15 points (n = 37)	BIS ≥ 15 points (n = 63)	χ2	P value
Age (years)			1.401	0.237
< 60	25 (67.57)	35 (55.56)
≥ 60	12 (32.43)	28 (44.44)
Sex			7.665	0.006
Male	27 (72.97)	28 (44.44)
Female	10 (27.03)	35 (55.56)
Educational attainment			0.059	0.809
Below senior high school	22 (59.46)	39 (61.90)
Senior high school or above	15 (40.54)	24 (38.10)
Disease progression stage			7.111	0.008
I-II	17 (45.95)	13 (20.63)
III-IV	20 (54.05)	50 (79.37)
Primary tumor site			1.158	0.560
Oral cavity	18 (48.65)	27 (42.86)
Oropharynx	7 (18.92)	18 (28.57)
Larynx	12 (32.43)	18 (28.57)
Multimodal treatment			4.927	0.026
No	33 (89.19)	44 (69.84)
Yes	4 (10.81)	19 (30.16)
Unemployment			7.565	0.006
No	15 (40.54)	10 (15.87)
Yes	22 (59.46)	53 (84.13)
HADS-A (points)			4.133	0.042
< 8	32 (86.49)	43 (68.25)
≥ 8	5 (13.51)	20 (31.75)
HADS-D (points)			5.313	0.021
< 8	31 (83.78)	39 (61.90)
≥ 8	6 (16.22)	24 (38.10)

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; BIS: Body Image Scale.

Table 6 Multivariate modeling of body image disturbance in head and neck cancer patients.

Variable	B	SE	Wald	P value	OR	95%CI
Sex	1.650	0.562	8.613	0.003	5.206	1.730-15.666
Disease progression stage	1.462	0.582	6.310	0.012	4.316	1.379-13.508
Multimodal treatment	1.907	0.753	6.416	0.011	6.730	1.539-29.427
Unemployment	1.242	0.610	4.142	0.042	3.461	1.047-11.444
HADS-A (points)	1.394	0.665	4.398	0.036	4.031	1.095-14.831
HADS-D (points)	1.306	0.633	4.249	0.039	3.690	1.066-12.767

HADS-A: Hospital Anxiety and Depression Scale-Anxiety; HADS-D: Hospital Anxiety and Depression Scale-Depression; CI: Confidence interval.

DISCUSSION

Patients undergoing treatment for head and neck malignancies commonly experience appearance-related side effects that precipitate body image concerns[16]. These changes may reduce self-worth, lower sexual drive, heighten social anxiety, and contribute to depressive symptoms, collectively impairing quality of life, personal identity, and emotional resilience[17]. Accordingly, this study aimed to characterize the psychological state and BID of patients with HNC and to identify associated determinants with the overarching goal of informing strategies to mitigate BID.

Our findings demonstrated the presence of psychological distress (anxiety: 25%, depression: 30%) among our cohort, predominantly of mild severity. These rates align with a previously reported pretreatment anxiety prevalence of 27% in HNC[18]. Reyes et al[19] revealed statistically higher frequencies (15%-50%) of anxiety and depressive disorders in HNC compared with other cancers, further supporting our results. Additionally, postradiotherapy depression rates of 29%-42% have been reported[20], validating our results. Subsequent assessment of body image revealed moderate distress among the cohort, with a mean BIS score of 16.00 (14.00, 18.00). Prior research indicates that body image issues in HNC evolve across the treatment trajectory: Pretreatment concerns often focus on disease status and treatment planning, whereas treatment-related sequelae, including visible disfigurement and organ dysfunction, may worsen BID[21]. Graboyes et al[22] observed increasing ΔBID scores for up to six months post operation in patients with HNC, with values not returning to baseline until nine months postoperatively.

Pearson’s/Spearman’s correlation analysis demonstrated significant positive associations between psychological state and all BIS domains, as well as the global scale, underscoring the close relationship between psychological distress and BID. Similar associations between elevated HAM-D/HAM-A scores and higher BIS values have been reported in patients with breast cancer[23]. Furthermore, sex, disease stage, multimodal treatment, unemployment, and HADS-A/HADS-D scores emerged as independent determinants of BID in patients with HNC. Specifically, female sex, stage III-IV disease, receipt of multimodal treatment, unemployment, and the presence of psychological distress (anxiety or depression) were associated with increased BID risk. These findings may reflect greater appearance-related and social pressures among women and the higher symptom burden and treatment-related toxicity associated with multimodal therapy. Consistent with our results, Macias et al[24] identified unemployment, multimodal therapy, free tissue transfer reconstruction, and limited formal education as predictors of BID HNC. Additional evidence from studies on dropped head syndrome in HNC has shown robust associations between BIS scores and age, laryngectomy status, lymphatic edema severity, and global functional outcomes[25]. Taken together, these findings support the implementation of integrated interventions. For female patients, efforts to minimize maxillofacial injury and provide positive psychological reinforcement may facilitate posttraumatic growth. Patients with advanced-stage or those receiving multimodal therapy require continuous monitoring to reduce treatment burden, integrating clinical and psychological assessments to enable timely intervention. Optimizing pain control and reducing complications remain essential. Finally, psychological support should be coupled with social assistance and resource linkage for unemployed patients to enhance overall well-being and alleviate BID.

Several limitations warrant consideration. First, unemployment status was not stratified by duration or cause (e.g., long-term vs Illness-related). Future longitudinal studies should clarify the timing and causes of unemployment to better delineate its relationship with BID. Second, the cross-sectional design precludes causal interference between BID and associated factors, including psychological state. Longitudinal investigations are needed to characterize temporal dynamics and causal pathways.

CONCLUSION

This study identified anxiety and depression prevalences of 25% and 30%, respectively, in patients with HNC, with both psychological conditions showing significant positive associations with BID. BID was influenced by sex, disease stage, multimodal therapy, unemployment, and psychological distress, with female sex and multimodal treatment exerting the strongest effects. These findings support the adoption of risk factor-oriented interventions in clinical practice, including enhanced psychological and social support for women and patients in the advanced stages, intensified symptom control and pain management for those undergoing multimodal treatment, and targeted social support and resource access for unemployed individuals.