Body image distress, self-esteem, and psychological adjustment following breast cancer surgery: a comparative and mediation analysis

Background Breast cancer surgery can substantially affect body image and self-esteem, particularly after mastectomy. Although breast reconstruction may be associated with more favourable psychosocial outcomes, the body-image dimensions underlying differences in self-esteem remain incompletely understood. This study examined cross-sectional associations among surgical status, body image, and self-esteem in women with breast cancer.Methods A multicentre cross-sectional study included 450 women: mastectomy with reconstruction (n = 150), mastectomy without reconstruction (n = 150), and a non-mastectomy comparison group (n = 150), comprising women without documented mastectomy at assessment. Self-esteem and body-image dimensions were assessed using validated questionnaires. Group differences were analysed using adjusted analysis of covariance, hierarchical regression, exploratory cross-sectional indirect-effect analysis with 5,000 bootstrap resamples, and multivariable logistic regression.Results Self-esteem and body-image scores differed significantly across groups after adjustment for sociodemographic and clinical characteristics (all p < 0.001). Women who underwent mastectomy without reconstruction reported the lowest self-esteem (26.7 ± 5.8), followed by women with reconstruction (32.9 ± 5.1), whereas the non-mastectomy comparison group reported the highest scores (37.4 ± 4.2). Appearance evaluation (β = 0.46) and fear of negative appearance evaluation (β = −0.34) were the strongest correlates of self-esteem (both p < 0.001). The final model explained 60% of the variance (adjusted R2 = 0.58). Body-image domains statistically accounted for approximately 89% of the cross-sectional association between surgical status and self-esteem. Recurrence history independently predicted low self-esteem (adjusted OR = 2.18, 95% CI: 1.29–3.68).Conclusions Body-image domains were strongly associated with self-esteem and statistically accounted for a substantial proportion of the cross-sectional association between surgical status and self-esteem. Women with reconstruction reported higher self-esteem than those without reconstruction, although scores remained lower than the non-mastectomy comparison group. Body-image assessment and psychosocial support may be valuable components of survivorship care; however, prospective studies are needed to evaluate targeted interventions.