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Retail Therapy (RT) and Body Image Distress

among Cancer Patients

Jay Yoo, Ph.D.
Simar Goyal

Abstract
The goal of this study is to conceptualize retail therapy (RT) in a broad range of cancer
patients to mitigate body image distress and promote positive health outcomes. Although the
impact of RT varies based on cancer type, diagnosis, body weight, and other demographic
characteristics, shopping provides a sense of control for cancer patients and boosts a positive self-
image. It is important to develop mitigation strategies using appearance-related behaviors and
products for patients with visible physical changes, regardless of gender. Research implications
and future research directions are suggested.

Introduction
Cancer patients place significant importance on their appearance when making decisions
about appearance-changing cancer treatments. Medically less desirable alternative treatments are
often chosen by cancer patients due to their body image concerns (White & Hood, 2011). It is
important to identify intervention strategies to boost body satisfaction for cancer patients so that
they can be more comfortable pursuing an optimum treatment course and maintaining a positive
attitude during treatment. Tiggemann and Lacey (2009) established that cancer patients, regardless
of gender, need fashion and accessories to manage and improve their appearance and presentation,
as well as to enhance their feelings about themselves.
Rudd and Lennon’s (2000) qualitative study on body image indicated that clothing was
spontaneously mentioned as a strategy to camouflage some bodily flaw, or as a means of self-
expression. However, the degree to which clothes shopping is effective in mitigating body image
52 TAFCS Research Journal 8(1), 2021

distress for a variety of cancer patients is not yet known. In addition, the existing literature
regarding cancer patients’ body image has focused primarily on women being treated for breast
cancer (White & Hood, 2011). Body image-related distress is a subjective experience that impacts
cancer patients because of various factors such as cancer type, diagnosis, pre-existing body image
concerns that is, body weight, and other demographic characteristics and personality variables.

Pikler and Winterowd (2003) mentioned that body image has often been overlooked as a
secondary problem by health care providers; thus, the significance of body image in the lives of
cancer patients has been underscored. They argued that cancer patients with better body image
perceptions had higher levels of self-confidence in fighting against cancer. Therefore, the
conceptualization of retail therapy (RT) on cancer patients’ body image distress will be used as a
foundation to design and influence the development of interventions that can alleviate body image
disturbance in a vulnerable population. Consequently, the goal of this study is to conceptualize
retail therapy (RT) in a broad range of cancer patients to mitigate body image distress and promote
positive health outcomes.

Cancer-Related Body Image Distress
Cancer Diagnosis and Physical Changes

Body image in cancer patients has been studied in a variety of cancers, predominantly
breast cancer (Ahmad et al., 2015; Cotrim & Pereira, 2008; Fauske et al., 2016; Harrington &
Badger, 2009; Manier et al., 2018; McClelland et al., 2015; Rhondali et al., 2015; Wortel et al.,
2015). Physical changes in each cancer patient present themselves differently, depending on the
severity and type of cancer diagnosis, even though patients undergoing radiation therapy all
experience multiple physical changes, regardless of the cancer type. Katre et al. (2008) found that
appearance concern was among the top three concerns in head and neck cancer patients.

Attractiveness characteristics are categorized into two parts: innate and mutable
characteristics. Innate characteristics include traits that cannot be altered such as height, facial
53 TAFCS Research Journal 8(1), 2021

bone structure, and body proportions (Franzoi & Herzog, 1987; Schulman & Hoskins, 1986).
Mutable characteristics include traits that individuals can control, including posture, body weight,
grooming, and facial expressions (Cash & Cash, 1982). The types of appearance changes that
cancer patients experience differ from innate characteristics to more volatile features (White &
Hood, 2011).

Patients’ perception of their disease is drastically altered by the visibility of their physical
changes to others (Fingeret et al., 2012). van Leeuwen et al. (2018) found that body image distress
was most frequently endorsed by breast and head and neck cancer survivors. Among the most
noticeable physical changes resulting from radiation therapy is hair loss. Cancer patients consider
hair loss a significant problem because it impacts patients’ treatment selection due to their desire
to maintain their physical appearance (Freedman, 1994). For example, most brain cancer patients
want to disguise their hair loss (Roe, 2011). Unhappiness with one’s appearance is a common
problem among young women with breast cancer due to chemotherapy treatment. Scars and body
weight changes were also sources of frustration and embarrassment for patients (Avis et al., 2004;
Demark-Wahnefried et al., 2001).

In addition, psychological adjustment to these physical changes is influenced by the degree
to which the changed appearance is permanent and the speed with which appearance changes
occur. Gradual loss of hair gives patients time to adjust, whereas the surgical loss of a body part
happens suddenly. Surgery that results in removing a body part may have either short-term or
permanent effects on one’s self-image. Many patients desire immediate surgical reconstruction
when these changes are reversible or minimized (White, 2002). Even if appearance changes are
not visible, they may negatively impact one’s body image and influence clothing choices due to
the significant psychological importance of surgery to an internal body part (White, 2002).

Appearance-related changes resulting from treatment are frequently ranked as more severe
than other side effects of cancer treatment. Physical appearance-related side effects such as scars,
54 TAFCS Research Journal 8(1), 2021

hair loss, and the need to use prosthetics are perceived as more distressing than side effects such as
fatigue, nausea, and insomnia (Tekkis et al., 2009). Patients with advanced cancer rank changes in
their body as equally or more important than fatigue, and physical changes are considered as a
burden (Rhondali et al., 2015). Chemotherapy-induced hair loss, also known as alopecia, can
cause stress and discouragement in cancer patients, which can impact their long-term health
outcomes. Trusson et al. (2017) demonstrated that women undergoing breast cancer treatment may
choose to disguise their hair loss with wigs, scarves, or hats. These fashion items can protect
patients from public scrutiny and allow them to conceal their cancer diagnoses. Therefore, retail
therapy (RT) is pivotal in building a conceptual framework to suggest intervention strategies for
cancer patients, which can help them enhance their self-image and emotional well-being.

Retail Therapy as Conceptual Framework
Anticipatory Coping and Control

Preparing to manage the stressful consequences of an upcoming event defines anticipatory
coping. Anticipatory coping involves using a routine to manage difficult events related to illness
and stressful circumstances, where cancer patients respond to the likelihood of physical experience
(Gignac, 2005). Initial appraisals regarding the consequences of treatment will be painful. RT can
positively impact emotional well-being by providing appropriate fashion products to camouflage a
patient’s perceived body flaws and reduce negative feelings associated with a cancer diagnosis.

According to Kaiser (1997), clothing serves important social and physical human needs;
moreover, it offers cultural representations and aesthetic value. In the United States, RT is a
prevalent shopping experience, showing significant results in mood elevation (Atalay & Meloy,
2011; Kang & Johnson, 2011; Johnson et al., 2014; Lee et al., 2015; Lennon et al., 1999; Rick et
al., 2014). Mick and DeMoss (1990) found that people purchase self-gifts when they are
disappointed or upset to elevate their mood. Anecdotal evidence collected by Rook and Gardner
(1993) also supports this proposition, with respondents indicating that impulse buying makes them
55 TAFCS Research Journal 8(1), 2021

feel better when they are in a negative mood. Mood adjustment or repair is a significant factor in
impulse purchases (Coley & Burgess, 2003; Dittmar et al., 1995). In addition, RT consists of
strategic consumption that reduces negative feelings and sadness (Atalay & Meloy, 2011; Rick et
al., 2014). Thus, the role of shopping on negative effects may be particularly salient for cancer
patients.

Kang and Johnson (2011) developed four distinctive constructs of RT: therapeutic
shopping motivation, positive mood reinforcement, negative mood reduction, and therapeutic
shopping outcomes. Therapeutic shopping motivation and outcomes refer to the therapeutic power
stemming from shopping and purchasing products. Kacen (1998) examined the motivations and
outcomes for therapeutic purchases and found that shoppers in negative moods frequently
purchase clothing, accessories, electronics, and food. For example, when a woman is dissatisfied
with her weight after trying on a pair of jeans that no longer fit, she may feel better about her
weight gain after shopping to compensate for their body weight. These purchases can reinforce
positive moods and alleviate negative moods (Edwards, 1993; Elliott, 1994).

Thompson et al.’s (1993) study on cancer patients with a range of different diagnoses
found a strong relationship between perceptions of control and successful adjustment to cancer
treatment. Control is a fundamental concept of emotional well-being, adjustment, and coping from
a psychological perspective (Walker, 2001). Activities in which cancer patients engage to manage
and cope with their physical changes are intended to provide patients gain control over their
situation (Frith et al., 2007). RT suggests that shopping can provide a sense of control in these
situations and boost a positive self-image (Aspinwall & Taylor, 1997). Clothing and other
appearance-management behaviors may become increasingly important for cancer patients,
providing a means of secondary or cognitive control over an inevitable and largely uncontrollable
disease.

56 TAFCS Research Journal 8(1), 2021

Cancer patients may have no control over their disease, but they can establish control by

wearing wigs and scarves, which will help them look healthy (Thompson et al., 1993). Frith et al.

(2007) suggested that cutting and shaving off one’s hair may serve a multitude of additional

functions, such as preparing oneself and others for the patient’s loss of hair, and feeling proactive.

Indeed, perceived control over daily emotions and physical symptoms is perceived as more

important than controlling the disease, relationships, or medical care (Frith, 2007). As a matter of

fact, cancer patients’ self-efficacy in coping with cancer is significantly impacted by higher or

lower body image perceptions (Cunningham et al., 1991). Women who feel better about their

bodies tend to have a stronger belief in their ability to keep healthy despite the disease and the

treatments, continuing physical and nonphysical intimacy with others.

In current practice, women who are scheduled to have chemotherapy that induces hair loss

are introduced to wig suppliers to choose their own wigs. Frith et al. (2007) found that most

female cancer patients felt better prepared for the onset of hair loss by trying out and purchasing

wigs or scarves. Female cancer patients also often have access to programs that teach them how to

use makeup, wigs, scarves, and hats to hide the effects of chemotherapy (Ucok, 2005; Ucok,

2007). However, there are mixed findings about whether these programs are effective in helping

women cope with hair loss (Weitz, 2004; Taggart et al., 2009). Wearing wigs and other forms of

headwear allow some women to feel control over their appearance. However, such strategies may

make other patients even more self-conscious about their cancer status because items such as wigs

and headscarves are symbolic of cancer treatment (Harcourt & Frith, 2008). In addition, Kim et al.

(2012) found that cancer patients are oftentimes not given adequate information about cancer-

related hair loss (Kim et al., 2012). Health care professionals may miss the opportunity to develop

effective interventions if they cannot identify effective coping strategies. Health care practitioners

could consider ways to enhance patients’ perceived control by using effective strategies on a day-

to-day basis. TAFCS Research Journal 8(1), 2021
57

Personality Variables

Body Investment

Cancer patients’ degree of body image-related distress is not merely a consequence of the

severity of physical changes alone; rather, body image-related distress involves the subjective

evaluation and experience of changes caused by an illness and its treatment (Fingeret, 2010;

Lehmann & Tuinman, 2018). Cash (2012) categorized appearance investment into self-evaluative

salience and self-motivational salience. Self-evaluative salience refers to the importance one

places on physical appearance in defining his or her self-worth and self-concept. Self-motivational

salience refers to one’s efforts to engage in appearance-management behaviors to improve his or

her attractiveness. Moreira, Silva, and Canavarro (2010) found that higher self-evaluative salience

predicted negative consequences of treatment, including lower quality of life, higher levels of

depression, and increased fear. However, higher levels of self-motivational salience predicted the

opposite. If patients are high in self-evaluative salience, their negative evaluation of their

appearance will be greater due to the increased fear of others’ negative evaluations about their

physical appearance. On the other hand, patients with higher self-motivational salience will make

more effort in their behavior to manage their appearance.

A self-evaluative component of body investment is frequently associated with clothing or

camouflage among cancer patients (Fingeret et al., 2010; Lehmann & Tuinman, 2018). Those

cancer patients who are not satisfied with their body changes may feel the need to cover up what is

perceived as an imperfection; therefore, they tend to put more effort into camouflaging their

bodies. Strategic apparel shopping would benefit cancer patients who are conscious about their

appearance and experience physical changes that differ from a societally prescribed “normal”

appearance. The impact of such body investment requires the consideration of additional factors,

including cancer type, diagnosis, body weight, other demographic characteristics, and body

investment in one’s appearance. TAFCS Research Journal 8(1), 2021
58

Demographic Variables
Age

The severity of cancer treatment on body image is likely to depend on the characteristics of
the disease and treatment and the patient’s chronological age (White, 2002). According to Can et
al. (2013), body image is poorer in younger (vs. older) cancer patients because younger patients
are more likely to focus on appearance than older patients. In addition, adolescents with cancer
have different body image concerns at different stages of treatment. For example, adolescents who
recently completed their treatment rated their body image better than those who had completed
their treatment more than one year previously (Pendley et al., 1997). After teens are discharged
from the hospital, changes in their appearance become more important to them (Freeman et al.,
2003). They fear an altered appearance more when undergoing chemotherapy than when they are
first diagnosed (Hedstrom, Skolin, & von Essen, 2004).

Hopwood et al. (2001) conducted a study with breast cancer patients younger than 55 and
older than 55 to explore the effect of age on body image. Results showed that younger patients had
more concerns about their body image. Nozawa et al. (2013) found that younger patients
experienced greater body image distress levels than older patients for gastrointestinal and lung
cancer. Fan and Eiser (2009) identified nine studies that assessed the relationships between the
cancer patients’ body image and age; no significant associations were found in seven of these
studies. Thus, there is insufficient evidence to conclude that older patients have a more positive
body image and cope better with their physical changes.
Gender

Gender is recognized as being a strong predictor of body image dissatisfaction (Cash,
2012). Due to more rigid cultural beauty ideologies, women in the United States experience higher
levels of body dissatisfaction than men (Franko & Strigel-Moore, 2002). Distress related to hair
loss, for example, is felt more strongly by female participants. The greater distress experienced by
59 TAFCS Research Journal 8(1), 2021

female participants relative to appearance symptoms may be an extension of their awareness and
concern, in general, relative to beauty and cosmetics (Swami, 2009).

Fan and Eiser (2009) identified 12 studies that addressed gender differences. Five studies
indicated that males rated their body image more positively than females (Eapen et al., 1999;
Enskar et al., 1997; Langeveld et al., 2004; Mullis et al., 1992; Wu & Chin, 2003); six studies
found no differences (Kopel et al., 1998; Kyritsi et al., 2007; Pendley et al., 1997; Stern et al.,
1993; Varni et al., 1995; Zebrack & Chesler, 2001). Only one study found that females rated their
body image better than males (Jamison et al., 1986).

Additionally, men place greater importance on physical attractiveness in their mate choice
than women, leading women to feel less satisfied with their physical abnormalities (Barrett et al.,
2002). The removal of female symbols such as long hair and large breasts due to cancer treatment
can negatively affect one’s body image. Tekkis et al. (2009) studied patients who underwent rectal
cancer excision and found that women reported having a poorer body image and being less
sexually active than men.

Although cancer treatments affect both men and women, Fan and Eiser (2009) found that
women felt greater distress about hair loss than men, and males appear to cope better than females
with appearance changes. Fingeret et al. (2012) suggested that gender fails to contribute to body
image scores due to the unique experiences of patients’ body image concerns when facing life‐
threatening illnesses. The clinical implications involve recognizing that male cancer patients are at
similar risk of experiencing body image difficulties as female cancer patients. It appears
reasonable to be concerned that male body image difficulties are perhaps more undetected. A more
concerted effort needs to be made by clinicians to help normalize these difficulties for their male
patients.

60 TAFCS Research Journal 8(1), 2021

Ethnicity
Schlebush and van Oers (1999) compared body image among Black and White female

cancer patients in South Africa and found that these women experienced their disease altogether
differently. Black patients were found to experience higher levels of depression and body image
dysphoria and used less adaptive coping strategies compared with White patients. Researchers
suggested that more research is needed because body image has not been investigated in people of
color, including Native Americans, Asian/Pacific Islanders, or multiracial patients in the United
States.
Socioeconomic Class

Substantial economic resources are allocated to appearance-enhancing products (Durante
et al., 2011). Young women’s body image concerns and compensatory behaviors significantly
influence their spending; therefore, socio-economic status has a significant impact on patients’
appearance-related concerns (Lucas & Koff, 2017). Women who are not satisfied with their
appearance tend to purchase more clothing, fashion accessories, jewelry, and body care products
to alleviate their body image distress (Lucas & Koff, 2017). Breast cancer patients who report
higher body image concerns tend to be more educated and have higher household incomes than
patients who report lower body image concerns (Cunningham et al., 1991). This is probably
because higher-income cancer patients tend to benefit from mood-regulatory functions that fashion
products can provide to them. Regardless, shopping and buying during therapeutic shopping trips
would significantly benefit cancer patients suffering from body image distress.

Overview of Body Image among Cancer Patients
White and Hood (2011) developed a multidimensional model of body image in oncology.
Clinicians and researchers are recommended to acknowledge the value that patients attach to the
body part affected by cancer. Considering the body image model in oncology by White and Hood
(2011), the conceptualization of cancer patients’ body image is developed based on a literature
61 TAFCS Research Journal 8(1), 2021

review concerning cancer patients’ body image based on the cancer type, personality, and
demographic variables.

Cash’s (2012) cognitive-behavioral model of body image highlights the influential role of
personality traits in developing body image attitudes. White (2002) delineated a cognitive-
behavioral model based on Cash's work, investigating the impact of cancer treatment on how
patients experience perceived or actual changes to their appearance. Considering the subjective
nature of body image is important in understanding the patient’s perspective, regardless of
physical changes noticeable to others. Cancer patients are concerned about reactions from others
when they perceive a large discrepancy from their body image ideal. On the other hand, cancer
patients with greater investment tend to be more resilient when they need to camouflage their
appearance.

The severity of body image distress is different based on the type of cancer and physical
changes. Visible physical changes are expected to result in negative reactions from others.
Moreover, cancer patients' body image experiences are significant when these changes are rapid
and permanent to the body, even though the physical functioning also affects cancer patients’ body
image. Patients who must decide whether to undergo appearance-changing cancer treatment need
support when evaluating their thoughts, beliefs, and feelings related to appearance changes so that
they can make an informed decision. Developing effective coping strategies using fashion items
will enable patients to adjust to the resulting changed appearance from cancer treatment.

Cancer patients’ perceived control in relation to their body image based on demographic
information requires further investigation. In particular, RT is conceptualized as a key element in
intervention strategies for cancer patients to compensate for their personal features and to rectify
their negative perceptions of a cancer diagnosis. Previous research has shown that shopping is an
effective way to minimize lingering sadness (Raghunathan et al., 2006). Impulse purchases can
alleviate the distress that arises from negative body image perceptions (Verplanken & Sato, 2011).
62 TAFCS Research Journal 8(1), 2021

In the context of cancer patients’ body image concerns, impulse buying may be helpful in
alleviating the distress that can arise from a cancer diagnosis and treatment.

Multiple changes in the body affect cancer patients’ attitudes toward their bodies, but there
is a hopeful sign that body image-related distress is subjective and not solely based on the severity
of the illness (Fingeret, 2010; Lehmann & Tuinman, 2018). Therefore, it is vital to identify what
constitutes clinically significant body image disturbance in cancer patients and survivors.
Oncology nurses may be in a particularly advantageous position due to their frequent patient
contact to apply the conceptualization of body image variables in cancer assessment and treatment.
Health care professionals have an inadequate knowledge of cancer patients' body image distress,
which in turn limits their ability to tailor communications with patients and their families. This
paper deepens the current understanding of shopping to diminish negative moods associated with
concerns about physical appearance and cancer symptoms.

This analysis has academic significance, as the study of appearance can broaden the scope
of research by integrating appearance within oncology. Cash et al. (2004) identified self-evaluative
appearance investment, which involves dysfunctional body investment and correlates with lower
self-esteem, a negative body image, and a lower quality of life (Cash et al., 2004). There are
therapies currently used for cancer patients, such as pet or animal-assisted therapy, which can ease
their anxiety and elevate their mood. RT can be one area that could gradually emerge as
significant in treating body image distress for cancer patients. The overview of the body image
dimension and intervention strategies to improve body image is illustrated in Figure 1. (See Figure
1).

_______________________
Insert Figure 1 about here

_______________________

63 TAFCS Research Journal 8(1), 2021

Conclusion
Body image assessment among cancer patients is significant because multiple changes in
the body affect cancer patients’ attitudes towards their bodies. There is a hopeful sign that body
image-related distress is subjective and is not solely based on the severity of illness (Fingeret,
2010; Lehmann & Tuinman, 2018). Developing effective coping strategies using fashion items
enables cancer patients to adjust to the changed appearance of cancer treatment. Healthcare
professionals have a limited understanding of cancer patients' body image distress, which, in turn,
limits their ability to tailor communications with patients and their families. Patients who must
decide about appearance-changing cancer treatment need support when evaluating their thoughts,
beliefs, and feelings about appearance changes to make an informed decision. Body image is
important for cancer patients’ short-term psychological benefit and long-term survival, especially
for patients who experience rapid or permanent changes. Clinicians and researchers need to
understand the value cancer patients put on altered appearance.

Future Directions
Further research needs to be conducted to develop effective intervention strategies that
demonstrate the effectiveness of Retail Therapy (RT) among cancer patients. It is important to
assess the effect of RT in a clinical setting, and to compare control and non-control groups to
confirm the effectiveness of RT. In addition, this research should focus on developing mitigation
strategies using appearance-related behaviors and products for patients with permanent visible
physical changes, regardless of gender. It is particularly beneficial to investigate patients from
diverse ethnic groups and all income levels due to the lack of empirical findings.
This review introduces body image as an area where psychotherapy can integrate RT to
benefit patients regarding their appearance. In the future, therapists could utilize fashion as a
reference for counseling. It is especially significant because the outcome of RT can improve
cancer patients’ body image. Highlighting the concept of therapy via fashion can contribute to
64 TAFCS Research Journal 8(1), 2021

apparel studies in other academic fields including oncology, psychotherapy, and counseling.
Fortunately, some of these developments are occurring. For example, Cash's cognitive-behavioral
program for body image self-help or therapy can be tailored to assist this population (Jarry &
Cash, 2011). The publication of cancer-specific body image assessment tools (Hopwood et al.,
2001) will likely assist in establishing validated models that can be used to guide assessment,
psychological and medical treatment, and outcome evaluation within cancer care settings.

Family and Consumer Sciences (FCS) scholars have identified the importance of
maintaining a healthy body image living in a complex world. Fashion merchandising professionals
should investigate the potential benefit of fashion-oriented consumption for those individuals
enduring cancer treatments. Individuals working in retail environments need to know the
importance of shopping to the mental and physical well-being of those individuals who experience
the side effects of cancer treatments. Child and family studies can look at solutions for working
with patients undergoing cancer treatments of all ages and their family caregivers. Understanding
the body image concern of cancer patients will provide strategies and opportunities for FCS
professionals to promote the positive body image of cancer patients and enhance their overall
quality of living.

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Figure 1.
Overview of Important Body Image Dimensions of Cancer Patients

74 TAFCS Research Journal 8(1), 2021

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