Impact of cosmetic care on quality of life in breast cancer patients

JEADV ISSN 1468-3083
© 2007 The Authors 771
JEADV 2007, 21 , 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
Blackwell Publishing Ltd
ORIGINAL ARTICLE
Impact of cosmetic care on quality of life in breast cancer patients
during chemotherapy and radiotherapy: an initial randomized
controlled study
G Titeca,*†§ F Poot,†§ D Cassart,‡ B Defays,† D Pirard,†§ M Comas,† P Vereecken,†¶††
V Verschaevec, P Simon,† M Heenen†
† Erasme University Hospital, Free University of Brussels, Belgium
‡ Institut de Statistique et de Recherche Opérationnelle and European Centre for Advanced Resaerch in Economics and Statistics, Brussels, Belgium
§ Notre Dame de Grâce Clinic, Gosselies, Belgium
¶ Bordet Institute, Brussels, Belgium, †† CHU, Brugmann, Brussels, Belgium
Keywords
cosmetic care, quality of life, breast cancer
*Corresponding author, Department of
Dermatology, Notre Dame de Grâce Clinic,
Gosselies, 212, chaussée de Nivelles, B
− 6041
Gosselies, Belgium, tel. [phone];
fax [phone];
E-mail: [email protected]
Received: 24 October 2005,
accepted 13 July 2006
DOI: 10.1111/j.1468-3083.2006.02080.x
Abstract
Background Breast cancer is the most common cancer in women and
therefore represents a major problem in public health. Data from patients’ self-
report questionnaires provide valuable information about the side-effects that
patients may view as having a significantly detrimental impact on their quality
of life (QOL) and yet are not always recognized as important by healthcare
professionals. Cosmetology is a specific care for patients and there is actually no
scientific evidence regarding effects on QOL for women with breast cancer.
Objective The purpose of this study is to assess the impact of cosmetic care on
QOL in breast cancer patients during chemotherapy and radiotherapy.
Methods We developed a prospective, multicentre, randomized, controlled
study including 27 patients. All the patients had to fill in a French-validated
dermatologic specific quality-of-life questionnaire to compare the QOL of the
two groups, the cosmetic group and the control group, at three different times
of the adjuvant treatment.
Results The results show a statistically significant difference between the
cosmetic group and the control group in two areas of QOL: mood state and self-
perception of the disease.
Conclusion This study emphasizes the interest of cosmetic care in breast
cancer patients. However, further larger trials are needed to confirm this study.
Introduction
Breast cancer is the most common cancer in women and
therefore represents an important problem in public
health.
1
Most patients with primary breast cancer can be
optimally treated with breast-conserving local treatments.
The addition of systemic hormone therapy and chemo-
therapy reduces the risk of death by 25–50% in patients
with invasive carcinoma.
2
These treatments are effective but are also sources of
side-effects; chemotherapy is particularly a source of effects
on the hair, nails and on the skin. On a psychological
and aesthetic point of view, alopecia is probably one of the
most difficult side-effects for patients. Moreover, disease
and cancer treatments contribute to modify patients’
perception of their own body, their ‘body image’.
Data from patients’ self-report questionnaires provide
valuable information about the side-effects that patients
may view as having a significantly detrimental impact on
their quality of life (QOL) and yet are not always recognized
as important by healthcare professionals.
Such information is very important in enabling patients
to make informed choices regarding treatment options.
3
However, there are still surprisingly few published reports

Impact of cosmetic care on QOL in breast cancer patients Titeca et al.
772 © 2007 The Authors
JEADV 2007, 21 , 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
from comprehensive QOL studies comparing such
treatments and thus little is known about the relative
impacts of each of these on QOL.
4–7
Cosmetology is a specific care offering not only face
moisturizing care, moisturizing massages, corrective
make-up, manicure, and pedicure, but also specialized
hair counsels (wigs, scarf, headband) to help patients to
take care of themselves and to correct the side-effects of
anti-cancer treatment such as alopecia, paleness, dryness
of the skin, scars, erythema, and nail dystrophy.
Unfortunately, so far there is no scientific evidence of
the benefit of cosmetology on QOL. The aim of our study
was to assess the impact of cosmetology and hair care on
QOL in breast cancer patients during the whole treatment
(chemotherapy and radiotherapy).
Materials and methods
Patients
Between January 2001 and August 2004, 27 female
patients aged 18 years old and over were included in two
centres (Erasme University hospital and Notre Dame de
Grâce Clinic Gosselies). Inclusion criteria were stage II
breast cancer treated by lumpectomy (excision of the
tumour with preservation of the breast) with positive
axillary lymph-node dissection receiving adjuvant chemo-
therapy and radiotherapy. Patients were treated either by
cyclophosphamide, methotrexate and fluorouracil (CMF)
or fluorouracil, epirubicin and cyclophosphamide (FEC)
administrated at intervals of 3 or 4 weeks for 4 months
(CMF) to 6 months (FEC). Approval for study was first
obtained from the local ethics committee.
Patients were informed of the target of the study and
were randomized in two groups, the cosmetic group and
the control group. The cosmetic group received cosmetic
care during the chemotherapy and the radiotherapy. The
control group did not received cosmetic care.
Methods
Patients were administered a French validated derma-
tologic specific quality of life questionnaire,
8
the VQ-
Dermato, including 28 questions about seven different
fields of QOL: self-perception, daily life activity, mood state,
social functioning, leisure/activity, treatment-induced
restriction, and physical discomfort
8
(Table 1).
All the patients had to fill in this questionnaire three
times during the adjuvant treatment: before the first
chemotherapy (time 0), after the second cycle of chemo-
therapy (time 1), and at the end of radiotherapy (time 2).
All the patients had an interview before the first cure of
chemotherapy (approximately 12 days before the first cure).
The patients of the cosmetic group received individual coun-
selling to choose the wig (model, colour), to do its mainten-
ance and to have refund by insurance company. Moreover,
this group received, by the same investigator (dermatologist
qualified in cosmetic care), a 2-h session including face
moisturizing care, body moisturizing massage with oils or
moisturizing creams, camouflage, manicure, pedicure and
make-up every month. Finally, they had an interview for
conclusion after the last session of radiotherapy (Table 2).
Data were analysed using the statistics software SPSS
12. Significance was assessed using the chi-squared or
Fisher tests and was set at P < 0.05.
Likert scale responses were arbitrarily subdivided in
two groups: never, seldom, not at all, somewhat, I don’t
know, not concerned corresponding to ‘ not altered QOL’
group, and sometimes, often, always, moderately, very
much, extremely corresponding to ‘altered QOL’ group.
Results
Patient’s characteristics
In the cosmetic group we find 14 patients age 39–60
(mean 51); 2 patients had CMF chemotherapy, 12 had
FEC chemotherapy, and all had radiotherapy.
In the control group we find 13 patients age 40–79
(mean 57), 1 had CMF chemotherapy, 12 had FEC chemo-
therapy, and all had radiotherapy (Table 3).
All patients except two developed alopecia, one in each
group.
Impact of cosmetic care on QOL
Table 4 show the number of patients (cosmetic group and
control group) for each responses group: ‘QOL not altered’
and ‘QOL altered’ at three different moments of the
treatment (times 0, 1 and 2).
Three questions showed a difference between the two
groups of patients but only after all the treatment (time 2).
Cosmetic patients were less discouraged than patients
receiving any cosmetic care (question no. 17/ P = 0.032).
Treated patients stayed more self-confident (question no.
23/ P = 0.032). Cosmetic patients stayed more confident
on the future (question no. 24/ P = 0.04).
We can thus notice that the treated patients keep a better
quality of life in two explored fields, the field of the ‘self-
perception of the disease “and the field of” mood state’.
Discussion
The quality of life becomes one useful tool in the medical
field, not only to analyse the impact of a disease but also
to evaluate impact of treatments.

Titeca et al. Impact of cosmetic care on QOL in breast cancer patients
© 2007 The Authors 773
JEADV 2007, 21 , 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
Table 1 VQ-Dermato questionnaire
VQ-Dermato in French (validated version) VQ-Dermato in English (indicative translation – not validated in English)
Durant les quatre dernières semaines, votre maladie a-t-elle entraîné des
difficultés:
During the 4 weeks, did your disease affect, restrict or
interfere with:
Q1 – pour marcher? Q1 – the way you walk or move?
Q2 – pour vous occuper de votre maison : ménage, cuisine, petits travaux
d’entretien?
Q2 – your housework?
Q3 – pour faire votre toilette, vous raser, vous maquiller? Q3 – your personal care (wash, ,shave, apply, make-up)?
Q4 – dans le choix de vos habits; vous n’avez pas pu mettre certains vêtements
ou ceux que vous souhaitiez?
Q4 – the chose of your clothes (you could not wear some of your clothes
you wished)?
Q5 – pour vos loisirs: sport, exposition au soleil, musique, bricolage,
jardinage?
Q5 – your recreation time: sport, sun exposure, music, do-it-yourself,
gardening?
Q6 – pour profiter du soleil, pour vivre dehors au soleil? Q6 – the way you enjoy the sun, you live in the sun?
Q7 – pour vous concentrer: travail, lecture? Q7 – your ability to concentrate (in working, reading)?
Q8 – pour dormir? Q8 – sleeping?
Durant les quatre dernières semaines, votre maladie vous a-t-elle gêné dans: During the 4 weeks, did your disease bother you in:
Q9 – dans votre vie sociale: sorties au restaurant, au cinéma, au café, allez
chez le coiffeur ou chez les commerçants … ?
Q9 – your social life: going to the restaurant, bar, hairdresser or
shopping … ?
Q10 – vos relations avec vos proches: famille, amis? Q10 – your relationship with your family and friends?
Q11 – votre vie affective avec votre conjoint(e), votre partenaire? Q11 – your sentimental life with your spouse or partner?
Q12 – votre activité sexuelle avec votre conjoint(e), votre partenaire? Q12 – your sexual relationships with your spouse or partner?
Durant les quatre dernières semaines, du fait de votre maladie, vous avez? During the 4 last weeks, did you feel:
Q13 – ressenti de la fatigue? Q13 – tired?
Q14 – éprouvé le besoin de cacher votre maladie de peau: par le maquillage,
les vêtements?
Q14 – that you had to hide your skin disease?
Q15 – eu les sentiments d’être dévisagé(e), rejeté(e) par les autres? Q15 – that people were staring at you or rejecting you?
Q16 – été stressé(e), énervé(e)? Q16 – stressed, irritable?
Q17 – été découragé(e)? Q17 – discouraged?
Q18 – été angoissé(e)? Q18 – anxious?
Q19 – été agressif, irritable? Q19 – aggressive, irritable?
Q20 – eu le sentiment d ‘être différent des autres? Q20 – different from the others?
Q21 – eu le sentiment d’être sale, repoussant? Q21 – dirty, repulsive?
Q22 – eu le sentiment d’être seule, isolé(e)? Q22 – alone, isolated)?
Q23 – eu le sentiment d’être diminué(e), de manquer de confiance en vous? Q23 – you were diminished, you lack self-confidence?
Q24 – manqué de confiance dans l’avenir? Q24 – no confidence for the future?
Durant les quatre dernières semaines, jugez-vous que le (ou les) traitement(s)
de votre maladie a (ont) été?
During the last 4 weeks, was the treatment of your disease?
Q25 – contraignant(s)? Q25 – restricting?
Q26 – désagréable(s)? Q26 – uncomfortable?
Durant les quatre dernières semaines, votre maladie a-t-elle entraîné: During the 4 weeks, did your disease cause:
Q27 – des démangeaisons? Q27 – itching?
Q28 – des brûlures, des picotements, des tiraillements ou toute autre forme
de douleur?
Q28 – burning, prickling, or any other type of pain?
Five Likert scale responses: Five Likert scale responses:
«Jamais, rarement, Parfois, Souvent, Toujours» for questions 1–8, 13–24 and
27, 28
‘Never, seldom, sometimes, often and always’ for questions 1–8, 13–24
and 27, 28
«Pas du tout , Un peu, Modérement, Beaucoup, Extrêmement / Enormement»
for questions 9–12 and 25, 26
‘Not at all, somewhat, Moderately, very much, extremely’ for questions
9–12 and 25, 26
+ Non concerné, Ne sait pas + Not concerned, I don’t know

Impact of cosmetic care on QOL in breast cancer patients Titeca et al.
774 © 2007 The Authors
JEADV 2007, 21 , 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
To date, in a surprising way, only a few publications deal
with the topic of QOL.
In order to study the impact of the cosmetic care on the
quality of life of the breast cancer patients in the course of
chemotherapy and radiotherapy, we developed a prospec-
tive, multicentre, randomized, controlled study including
27 patients. In spite of little information about all the
QOL, this study shows significant differences between
the two groups of the patients but only at the end of the
treatment; indeed at this time, patients who received
cosmetic care remain more self-confident and are more
optimistic.
The fact that the difference is only significant at the end
of the treatment shows that it is interesting to follow the
patients throughout treatment and not only during one
session of chemotherapy or radiotherapy.
Although no study was carried out among breast cancer
patients, we know that self-confidence is altered in these
patients and this might interfere with their compliance to
treatments.
9,10
Therefore, it should be important to focus on patients’
psychological life and to develop all kind of support that
can help them to stay hopeful and confident about the
future as illustrated in our trial. We really think that
cosmetology is helpful and the most important support
for women is probably hair care because of its significant
impact on the ‘body image’.
Moreover, we insist on the fact that this study was entirely
free for patients and that the financial aspect could represent
a brake with the cosmetic care for some patients. There-
fore, it seems important to analyse possibility of a financial
support by the health insurances or government. It could
also realized by cosmetic company as it is already the case
in France for the association ‘L’Etincelle’ devoted to the
quality of life of the women suffering from breast cancer.
In our study, all the cosmetic care was provided by
people properly trained in ‘hospital cosmetic care’. Un-
fortunately they are currently very few. To develop this
approach on a large scale, it seems possible to us to set up
a nurse training elaborated by people experienced in
cosmetology and oncology. Cosmetic care provided by those
specially trained nurses stand be available in gynaecology
departments treating breast cancer and in oncology
departments and could be extended to other male and
female cancers patients as well.
Acknowledgements
This study was supported by a grant provided by Lancôme
Belgium.
Table 2 Programme o
f
the meetings
Control group Cosmetic group
12 days after the 1st cure of chemotherapy (1st time): Meeting 12 days before the 1st cure of chemotherapy (1st time): Meeting
Planning explanation + delivery of the list of the advised
Belgian wig makers + VQ-Dermato to fill in at home
First visit: Planning explanation + Proposal of a hair cut very short before the possible
loss of the hair + choice of capillary prosthesis + delivery of VQ-Dermato to fill in at home
12 days after the second cure (2nd time): 12 days after the second cure (2nd time): Meeting
VQ-Dermato to fill in at home. Sent by post mail Planning for Cosmetic Care and first séance of cosmetic care + VQ-Dermato to fill in
at home. Specific cosmetic care programme established for each patient with the
dermatologist
After the last radiotherapy (3rd time): After the last radiotherapy (3rd time): Meeting
VQ-Dermato to be fill-in at home. Sent by post mail Conclusions + VQ-Dermato to fill in at home
Table 3 Patient’s characteristics
Mean age
(years)
Number of patients
CMF chemotherapy
Number of patients
FEC chemotherapy
Number of patients
radiotherapy
Cosmetic group 51 (39 to 60) 2 12 14
14 patients
Control group 57 (40 to 79) 1 12 13
13 patients

Titeca
et al.
Impact of cosmetic care on QOL in breast cancer patients
© 2007 The Authors
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JEADV
2007,
21
, 771–776 Journal compilation © 2007 European Academy of Dermatology and Venereology
Table 4 Statistics – Fisher test
Responses group
Time 0: before treatment Time 1: during treatment Time 2: after treatment
QOL not altered
Number of patient
QOL altered
Number of patient
P -value
QOL not altered
Number of patient
QOL altered
Number of patient
P value
QOL not altered
Number of patient
QOL altered
Number of patient
P valuePatient’s group Control Cosmetic Control Cosmetic Control Cosmetic Control Cosmetic control cosmetic Control Cosmetic
Question 1 12 12 1 1 0.760 8 12 1 0 0.429 8 11 3 0 0.107
Question 2 11 9 2 4 0.322 6 9 3 3 0.523 8 9 3 2 0.500
Question 3 13 13 0 0 / 8 12 1 0 0.429 10 10 1 1 0.762
Question 4 13 13 0 0 / 8 12 1 0 0.429 9 9 2 2 0.707
Question 5 10 9 3 4 0.500 7 9 2 3 0.647 8 9 3 2 0.500
Question 6 12 10 1 3 0.297 6 10 3 2 0.353 9 8 2 3 0.500
Question 7 10 9 3 4 0.500 8 9 1 3 0.414 6 8 5 3 0.330
Question 8 5 7 8 6 0.348 5 8 4 4 0.472 8 7 3 4 0.500
Question 9 12 11 1 2 0.500 8 10 1 2 0.612 9 9 2 2 0.707
Question 10 13 12 0 1 0.500 9 12 0 0 / 9 10 2 1 0.500
Question 11 13 12 0 1 0.500 9 12 0 0 / 10 11 1 0 0.500
Question 12 13 11 0 2 0.240 9 8 0 4 0.083 9 8 2 3 0.500
Question 13 3 6 9 8 0.296 4 5 5 7 0.623 2 4 9 7 0.318
Question 14 12 13 0 1 0.538 7 11 2 1 0.388 11 11 0 0 /
Question 15 12 14 0 0 / 8 11 1 1 0.686 10 11 0 1 0.500
Question 16 7 10 5 4 0.387 3 8 6 4 0.142 6 7 5 4 0.500
Question 17 8 11 4 3 0.404 5 10 4 2 0.183 5 10 6 1 0.032
Question 18 7 9 5 5 0.536 4 7 5 5 0.425 5 8 6 3 0.193
Question 19 11 12 1 2 0.560 8 9 1 3 0.414 7 9 4 2 0.318
Question 20 11 12 1 2 0.560 6 9 3 3 0.523 9 9 2 2 0.707
Question 21 12 14 0 0 / 11 8 1 1 0.686 10 10 1 1 0.762
Question 22 11 14 1 0 0.463 8 11 1 1 0.686 9 10 2 1 0.500
Question 23 10 12 2 2 0.641 6 8 3 4 0.681 5 10 6 1 0.032
Question 24 10 13 2 1 0.440 6 8 3 4 0.681 4 9 7 2 0.040
Question 25 9 9 3 5 0.437 9 8 0 4 0.083 8 8 3 3 0.682
Question 26 7 11 5 3 0.246 8 8 1 4 0.258 10 10 1 1 0.762
Question 27 10 14 2 0 0.203 9 11 0 1 0.571 8 11 3 0 0.107
Question 28 7 10 5 4 0.387 8 10 1 2 0.612 8 7 3 4 0.500