“I listen to my body now”: a qualitative exploration of positive body image in breast cancer survivors 

Abstract Objective Existing research has identified the high prevalence of body image concerns among female breast cancer survivors. However, it has neglected to explore the experience of positive body image among this group, despite its potential utility for intervention development. The present study therefore aimed to explore the experiences of breast cancer survivors who self-identified as experiencing a positive relationship with their post-treatment bodies. Design Twenty-two participants (M age = 54, SD = 8.38) were interviewed using a semi-structured approach. Results Thematic analysis identified three overarching themes amongst the qualitative data: (1) Resisting appearance pressures, (2) Receiving care, and (3) Self-worth beyond appearance. Findings indicated that women’s life experiences had led them to develop a critical awareness of the unrealistic nature of appearance ideals. Their experience of positive body image was also attributed to engaging in self-care and receiving supportive care from others. Finally, women expressed prioritising functionality and health over their physical appearance. Conclusion The present findings advance the theoretical understanding of positive body image in a breast cancer population. They also provide an opportunity to test theorised models of positive body image.


Introduction
Breast cancer is the most commonly diagnosed cancer among women worldwide (World Health Organisation, 2021). Women who undergo treatment for breast cancer are often left with changes to their appearance, including scarring, breast asymmetry, hair loss, weight changes, burns, and changes to the appearance of skin and nails (Collins et al., 2011;Hesketh et al., 2004;Hopkins et al., 2017;Nozawa et al., 2013). Given that up to 78% of women survive for 10 years following diagnosis (Quaresma et al., 2015), there is a large population living with a wide array of treatment-related appearance changes. Research indicates that body image distress is both common and long-lasting, following treatment for breast cancer (Begovic-Juhant et al., 2012;Fouladi et al., 2013;Lemieux et al., 2008). This evokes concern, as adverse psychological consequences (e.g., anxiety, depression and intrusive thoughts; Lam et al., 2012) have been identified by longitudinal research. Although body image concerns have received recognition as an issue affecting many women treated for breast cancer, research has overlooked the group of women who report feeling more accepting of their post-treatment bodies. Research indicates that between 27% and 77% of women treated for breast cancer experience body image concerns to some extent (Begovic-Juhant et al., 2012;Falk Dahl et al., 2010). Whilst such variation in figures may relate to differing sample characteristics and measures across studies, it may also suggest a proportion of women who are less vulnerable to treatment-related appearance concerns; instead experiencing a greater degree of positive body image.
Positive body image has been defined as 'an overarching love and respect for the body' , which allows appreciation of appearance and function and an awareness of the body's needs (Wood-Barcalow et al., 2010, p.122). Positive body image is argued to be distinct from negative body image (i.e., dissatisfaction, concern or distress related to appearance; Thompson et al., 1999). Each represent their own continuum, and individuals can consequently experience both positive and negative body image simultaneously (Tylka & Wood-Barcalow, 2015). In 2010, Wood-Barcalow, Tylka and Augustus-Horvath proposed a model of holistic body image which conceptualizes how biological, sociocultural and interpersonal factors interact with the way in which individuals 'interpret and internalise information about their bodies' (Wood-Barcalow et al., 2010, p.111) to influence body image. This theory argues that positive body image is characterised by a shift in cognitions relating to body acceptance and appreciation, conceptualisations of beauty, and the filtering of appearance related information (Wood-Barcalow et al., 2010). Taking care of the body through health-related behaviours, in addition to maintaining relationships with others, are also considered to be important in the experience of positive body image (Wood-Barcalow et al., 2010). The holistic body image model also postulates that body image is fluid, as suggested by the interaction between processing of positive and negative appearance-related information, body image investment (i.e., the importance, meaning and influence of appearance in one's life; Cash et al., 2004), and body image evaluation (i.e., how an individual appraises their body; Ozimok et al., 2015).
The study of positive body image is growing at pace and has been primarily focused on the general population. Empirical research from college students and older adults has found that body appreciation is positively related to appearance satisfaction and psychological wellbeing, whilst inversely associated with body image concerns (Avalos et al., 2005;Swami et al., 2008;Tylka, 2013). Albeit limited, research conducted in populations with a physical disability indicates commonalities in the experience of positive body image with able-bodied individuals (Bailey et al., 2015). However, other studies have also identified condition-specific aspects of positive body image (e.g., appreciation of retention of function in the upper body in a spinal cord injury; Bailey et al., 2015), thus emphasising the importance of examining positive body image among individuals with different conditions. At present, research exploring positive body image among women with breast cancer is scarce. One qualitative study suggested a dichotomous construction of body image following treatment for breast or bowel cancer . This was characterised by feeling satisfied with some appearance-related aspects of the post-treatment body (e.g., body shape), whilst concurrently feeling distressed by others (e.g., hair loss from chemotherapy). Other research has identified themes of body appreciation, acceptance of altered appearance, body confidence, and the perceived importance of a healthy body Sun et al., 2018).
Collectively, these findings highlight the complexities and multifaceted nature of body image among women who have undergone treatment for breast cancer. However, whilst these studies have made a promising start in exploring positive body image, they are limited in numerous ways. First, they have either combined individuals with different cancer diagnoses (i.e., breast and bowel cancer) within the same sample  or only focused on a specific treatment subgroup of women (e.g., those who have undergone mastectomy; , thus limiting generalisability of the findings to a broader group of breast cancer survivors. Second, these studies explored body image more broadly, without focusing specifically on the experience of positive body image. Therefore, further research is necessary to enhance our understanding of the experience of positive body image among breast cancer survivors.

The present study
The present study aimed to explore the experience of positive body image among breast cancer survivors who had undergone any modality of treatment, in order to gain insight to the mechanisms that foster adaptation to, and acceptance of, their post-treatment bodies. This study also aimed to contribute to the broader literature regarding positive body image in individuals with visible differences, as this is currently lacking (Halliwell, 2015).

Design
A qualitative design was employed in order to gain an in-depth understanding of the experiences of positive body image in breast cancer survivors (Braun & Clarke, 2013). Telephone interviews facilitated sharing of potentially sensitive information by allowing participants a sense of anonymity (Novick, 2008); whilst also obtaining a greater geographical representation of participants (Sturges & Hanrahan, 2004). The interviews were semi-structured in nature, which allowed for a participant-led exploration of the breast cancer experience, whilst remaining focussed on the key topic (Rabionet, 2011).

Recruitment
With regard to inclusion criteria, participants had to be female; at least 18 years of age; and have received a diagnosis of breast cancer or DCIS (Ductal Carcinoma in Situ); for which they had finished their active treatment (i.e., had undergone surgery and finished chemotherapy/radiotherapy, but may still be receiving hormone treatment). To be eligible, participants also had to self-identify as feeling positive about their post-treatment body in some way. This was facilitated by providing examples of how someone experiencing positive body image might feel in relation to their body (e.g., 'some women might feel appreciation or gratitude towards their post-treatment body because it allowed them to survive the cancer treatment and they are now healthy' or 'some women might feel good about their post-treatment body because it allows them to do things they enjoy') and a definition of positive body image from the literature ('an overarching love and respect for the body, which allows appreciation of appearance and function and an awareness of the body's needs' , Wood-Barcalow et al., 2010). Breast cancer support groups based in (country) were contacted via email over a period of 3 months (between January 2018 and March 2018) and agreed to advertise the study. Interested parties contacted the first author to enquire about participation.
This recruitment strategy resulted in a sample of women who had undergone a diverse array of procedures to treat their breast cancer. All women included in the sample expressed their motivation to contribute to future knowledge and support for women like them. Many of the women also had already undertaken some kind of volunteering or awareness raising role to help support other women with breast cancer. Therefore, the women in this sample had close links with charities and support groups. This could also have had a role in their recovery and adaptation to life after cancer treatment.

Participants
In total, 22 female participants were interviewed. Saturation was noted in the sample after 18 interviews, however, 4 further interviews were conducted to ensure no new information was generated (Sandelowski, 1995). The mean age was 54 years (SD = 8.38, range = 36-71) and nearly all participants identified as White (95%). All women identified as being heterosexual, with most reporting being married or in a civil partnership (64%). The majority of women were educated to bachelor's degree level or higher (55%). Twenty-one (95%) women reported having children. Many women indicated having been diagnosed with invasive breast cancer at either Stage II (27%) or III (55%). Most women had undergone a mastectomy (82%), with half of these women also having undergone breast reconstruction (41%). A mean of 49 months (range = 3-168 months [14 years]) had elapsed since the end of active treatment. Further demographic and medical data concerning the participants is presented in Table 1.

Procedure
The present research received university ethical approval (approval code: MDRA2). Participants were initially provided with an information sheet, which directed them to a Qualtrics page. Here they indicated their consent, and subsequently completed a short demographic questionnaire. Participants were then contacted by the first author to arrange a convenient time to conduct the telephone interview. Interviews lasted between 30 and 70 minutes (mean duration = 37 minutes) and followed a semi-structured interview schedule. This interview schedule (see Appendix) was informed by existing literature in the fields of breast cancer and body image (e.g., ; paying special attention to theorised models of positive body image, including the theory of body appreciation (Avalos et al., 2005), the holistic model of body image (Wood-Barcalow et al., 2010), and the developmental theory of embodiment (Piran & Teall, 2012). These models informed the topic areas to be explored in the interview schedule, such as media influences, social support, embodiment, and body functionality. All interviews were audio-recorded and transcribed by the first author. The first author was a female researcher who had no personal experience of breast cancer. Telephone interviews were selected to facilitate a broader reach of participants. This mode of data collection is beneficial as it allows participants to take part from the comfort of their own home, which can make them more relaxed and comfortable to disclose sensitive information (Novick, 2008). However, the limitations of telephone interviews also warrant acknowledgement. For example, the researcher does not have access to non-verbal cues, such as body language and facial expressions (Opdenakker, 2006). In addition, they cannot see the participant's surroundings to make judgements about potential distractions during the interview (Opdenakker, 2006). Despite these limitations, the advantages of conducing telephone interviews informed the decision to use this method.

Data analysis
Thematic analysis (TA) was employed to analyse the qualitative data. A critical realist perspective underpinned the study design. Critical realism proposes that there is an authentic reality, which is socially influenced, but can be accessed via research (Houston, 2001). Critical realism highlights that there is a reality that we can access and investigate in order to bring about change. (Stainton Rogers & Stainton Rogers, 1997).
The first author carried out analyses on all transcripts using six-stage TA as described by Braun and Clarke (2006). To ensure transparency of the process (Meyrick, 2006), the first author kept a record of the analysis. The first step of the analysis was to read through all the transcripts and make notes regarding initial thoughts, in order for the researcher to familiarise themselves with the data. Next, initial coding of the transcripts took place, and followed the alphabetical order of the participants' pseudonyms. The first author then completed a second coding of the data in a different order; using the numerical order of the participant unique codes. A compiled list of the codes and extracts was subsequently used to develop emergent themes. Throughout this process, themes were checked against the codes and extracts to ensure that they were representative of the meaning of the raw data. Thematic mapping was also employed to identify connections between themes. Themes were then defined, named, and once again checked against the initial codes to ensure that the names and definitions accurately reflected the data. The first and second author met regularly to discuss the analysis process and any ambiguity around coding. In accordance with quality criteria regarding rigour of collection and analysis (yardley, 2000), the coding of a subset of transcripts was also reviewed by the second author. Any discrepancies were discussed between the first and second authors until they were resolved.

Results
The present study aimed to explore the experience of positive body image in breast cancer survivors. Participants described their diagnosis and treatment journey, with a particular focus on how treatment-related appearance changes and changes to body functionality influenced the way they viewed their bodies. Participant narratives indicated the influences of personal circumstances and sociocultural environments on their experience of positive body image. Three main overarching themes were identified: 1) Resisting appearance pressures, 2) Receiving care, 3) Self-worth beyond appearance.

Resisting appearance pressures
This theme reflects the way in which participants described interacting with sociocultural norms relating to appearance ideals for women. Participants acknowledged their long-standing (i.e., pre-cancer) exposure to narrow beauty ideals from different media sources. However, they also noted feeling protected from their adverse impacts, as they understood that these ideals were not realistic nor representative of their own lives.

But that's not real life
All women reported being aware of both society's narrow appearance ideals for women (e.g., slim bodies, youthful appearance, symmetrical breasts) and their sources (e.g., television, magazines and social media). However, most women reported feeling less influenced by these appearance ideals, due to their ability to 'reframe' and critique their associated messages as unrealistic. Participants acknowledged that these images were likely to have been altered through airbrushing and editing methods, or the models selected in order to promote one specific body type. They were therefore aware that these images were neither representative of real-life nor realistic for women to achieve.
Julie talked about how appearance ideals set women up to fail, as they would never be able to achieve them. She discussed the importance of resisting the pressures associated with these ideals, given the potential for negative impact on self-esteem 'if you let it' . "Well, I think it sets us up for failure. to be honest. Because realistically. most of them are sat in front of the mirror having their hair and make-up done for hours. or been airbrushed out. But the rest of us living in the real world. and actually. that's not realistic, and actually. that can have an impact on your body image and your self-esteem, if you let it" Julie, 53 Alex discussed how narrow appearance ideals conveyed by the media were unrealistic, because they did not reflect the people she knew in her real life.
"you know. if you walk around town or stand in the school playground. a lot of people aren't size 10 or a size 12" Alex, 45 These women described a process of distancing themselves from narrow appearance ideals, thus indicating a lower degree of internalisation of such ideals.

Age is protective
Many women referred to their age (M age = 54) as being influential in the way they felt about their post-treatment bodies. Women described feeling somewhat removed from the typical concept of youthful beauty, given that their bodies were ageing naturally. Further, this served to protect them from expecting perfection from their body in the same way they may have done when they were younger.
Esmerelda discussed how the ageing-related changes to her body helped her feel less self-conscious about her appearance. She also talked about her lower expectations of perfection from her body, and how she had become less critical of her appearance with age.
"I think a lot of it is also age. It [the body] changes with age and I'm less self-conscious. I don't expect perfection anymore. I probably find it easier to live with because I've seen more and I'm more experienced. I don't expect that kind of flawless perfection" Esmerelda, 55 Women described their age as protective against experiencing body image concerns. This was attributed to experiencing less pressure to conform to the appearance ideals of youthful beauty and feeling greater comfort with their bodies as they age.

Receiving care
Accepting care from others, whilst simultaneously engaging in self-care, was identified as a main theme within the experiences of the women interviewed. Participants described the positive impact of a caring and self-compassionate approach on the way that they felt about their bodies. Women reported recognising their physical and psychological needs and prioritising self-care behaviours following treatment. Participants also discussed the benefit of receiving social support from others, and its role in supporting them to accept both the appearance and functionality of their post-treatment bodies.

Looking after me and my body
The majority of women described engaging in behaviours that embodied a caring and compassionate approach towards themselves and their bodies. Women also reported experiencing increased awareness of their bodies and their physical and psychological needs, as well as increased prioritisation of being responsive to those needs. Women often talked about the importance of this approach in maintaining or restoring health and function to their bodies. Women recounted examples of traditional self-care behaviours, such as taking time out to rest, going for massages, listening to the body and practicing self-compassion. In addition, participants described carrying out health behaviours (e.g., exercising, eating well).
Beth highlighted that prior to her cancer diagnosis; she would not pay attention to when her body needed rest and care. She reported feeling more attuned and responsive to her body's needs, due to developing greater awareness of her body during breast cancer. She also talked about the practices she engaged in to 'treat' herself and her body. "Um. I just rest when I need to rest. and I sort of. I listen to my body now. Before, I used to. 'oh, never mind, carry on' , but now, if I know I can't do something. I'm feeling tired. then I just have a rest. I listen to my body and I still look after myself. I treat myself. If I go and have a facial and like a back massage. when I come out of it, it's like my face is breathing and my muscles in my back are relaxed" Beth,53 Some women talked about the benefits of practising mindfulness and self-compassion in helping to adopt a more caring approach towards themselves, after struggling with self-criticism. Emily spoke about how learning to treat herself with more kindness had contributed to her wellbeing.
"I did a course in mindfulness and compassion. and I think that was really good for me, because I struggled with a lot of self-criticism. I've just learnt to be kinder to myself. and I think that's been really helpful for my general wellbeing" Emily, 37 A common experience among women was adopting a caring approach to their bodies following diagnosis and treatment. This allowed them to better understand and devote time to self-care during their recovery and beyond.

Care from the community
All women talked about the care they received from sources of social support, including friends and family, support groups, healthcare professionals, and close others, such as colleagues and neighbours. This helped to affirm positive feelings about their bodies during their experience of breast cancer. Participants described the different elements of social support that they found beneficial.
Many women spoke about how positive feedback and acceptance from close others about their post-treatment bodies helped them accept their altered physical appearance. Emma articulated the benefits of receiving compliments about the differing colour and texture of her hair regrowth following chemotherapy: "I have had a lot of support from friends, so. and even though I lost my hair and my hair regrew really weird and curly and grey, everyone thinks it's fantastic. So, I am getting a lot of positive input from umm. my friends and my family" Emma, 50 The majority of women also found that seeking and receiving practical support allowed their bodies the opportunity to rest and recover; helping restore their functionality. Emily spoke her partner's support by taking over practical responsibilities around the house. This allowed her to focus on healing and recovery following treatment: "I think. because my husband took a lot of the responsibilities for sort of running the house. and he was doing it before anyway. but even more so. I wasn't able to while I was having treatment, so he kind of helped in that way. so that kind of took the pressure off me and enabled me to just kind of focus on the health aspect and being well" Emily, 37 Care from others, in various forms, supported these women to feel accepted and cared for by members of their community. This not only affirmed positive feelings about their post-treatment bodies, but also gave them prompts and opportunities to appreciate their own bodies, in addition to time to heal physically from their treatment.

Self-worth beyond appearance
All participants acknowledged the value of their bodies beyond their physical appearance. For these women, restored or continued functionality enabled them to feel positive about their bodies following treatment. Women also highlighted health as their priority in relation to their bodies, as opposed to their appearance.

Health is the priority
Many women discussed how they were more focussed on survival; being cancer-free and physically well again, than their treatment-related appearance changes. Some women described how their treatment-related decision-making process was informed primarily by their wish to be cancer-free, as opposed to concerns regarding anticipated appearance changes. Betty talks about how it seemed irrational to increase her risk of recurrence for the sake of keeping her other breast (she opted for a bilateral mastectomy).
"I decided to go for the bilateral mastectomy, so I didn't have to go back. Because the idea of getting cancer in my other breast, and then having to go through the whole thing again. it just seemed ridiculous. If you haven't got breasts, you can't get breast cancer. That was my theory." Betty, 57 The majority of women expressed gratitude towards their bodies for surviving the cancer. They were grateful that they were strong and resilient through the treatment, and that they were now healthy. Monica talked about how survival from the cancer was far more important to her than her post-treatment appearance; thus, leaving her less vulnerable to experiencing body image concerns. "you know. the most important thing is being alive. That's what life is about. not what your body looks like. So, it's never been an issue for me" Monica, 54 Emily described her appreciation for, and surprise at, the strength and resilience that her body showed when going through treatment, and how this experience led her to feel a new sense of confidence in her body.
"I was just surprised with what my body could take and what it could handle. I think it's actually quite strong, I feel like it could handle most things" Emily, 37

Actions over appearance
Participants spoke about investing greater importance in what their body was able to do rather than its physical appearance following treatment. All women described feeling appreciative of their body for being functional in a way that was meaningful and enjoyable to them, such as being able to spend time with their family and engaging in hobbies they had pursued prior to their cancer diagnosis. Jacqui talked about her body allowing her to engage in activities that were important to her well-being and lifestyle.
"My body functions in order to allow me to do what I want to do. so, you know. I can ride horses, I can ride my bike, I can run, I can walk the kids to school" Jacqui, 36 Some women with children also commented that they did not feel sad or angry, as their bodies had already had the opportunity to be fertile, carry and have children, and to breastfeed. They believed this helped protect them from feeling negative about their body.
Susan highlighted that chemotherapy-related fertility fears were not relevant to her. However, she recognised that she would have felt differently had she not had the opportunity to have children prior to her diagnosis. In addition, Alex spoke about feeling a sense of appreciation for her body having already borne her children.
"Having the chemotherapy and everything. you know. I don't have to worry about all that, and it doesn't affect me in that way. So, you know. because I've had my children. I think I would feel very angry if I was young and I hadn't had any children yet" Susan, 55 "My body has borne me two beautiful children, thank goodness. before I got cancer. And you know. I breast fed my second child. My body has done the womanly thing that is was designed for" Alex,45 These quotes indicated that women were appreciative of their bodies for being able to carry out roles they felt were important to their self-identity, including participation in family life and the pursuit of personal interests.

Discussion
The aim of the present study was to explore the experience of positive body image among women who had undergone treatment for breast cancer. Three overarching themes emerged from the data. The first theme ('resisting appearance pressures') reflected the relationship that women held with narrow societal appearance ideals; whereby they were critically aware of their unrealistic nature, and thus were less likely to internalise these standards. The second theme ('receiving care') described the self-compassionate and caring approach that women took with themselves and their own bodies, in addition to the care that they received from others. The final theme ('self-worth beyond appearance') captured the view that health and function were considered of greater importance than physical appearance. These findings contribute to the field by advancing our understanding of the experience of positive body image among women who have received treatment for breast cancer.
In the present study, breast cancer survivors who identified as feeling positive about their bodies reported feeling unaffected by images conveying narrow appearance ideals. Sociocultural models of body image propose that narrow appearance ideas are conveyed through our social and cultural environments and experiences. For example, Objectification theory argues that women are exposed to the Western practice of sexualisation of the female body, which adheres to narrow appearance ideals (portrayed commonly in media), and this leads them to self-objectify (i.e., view themselves as objects for use instead of as human beings; Fredrickson & Roberts, 1997). Further, the Tripartite Influence Model posits three sources of influence which are responsible for communicating and reinforcing appearance ideals: the media, family and; and two mechanisms by which their pressure leads to body dissatisfaction: internalisation of appearance ideals and appearance comparisons (Thompson et al., 1999). Women in the present study reported being able to counteract exposure to and pressure of appearance ideals through an ability to filter and 'reframe' these images as unrealistic or lacking in relevance to their own lives, which consequently protected them from internalising these ideals.
Findings also suggest that these women possessed media literacy (i.e., the ability to critically evaluate media), which aligns with previous research conducted with women with breast cancer. Following the pilot of an intervention that taught media literacy skills to women who had received treatment for breast cancer, these women highlighted feeling greater appreciation and acceptance of their bodies (Lewis-Smith et al., 2018). Qualitative research suggests that women's acceptance of their post-treatment body could be seen as a rejection of social discourses that a women's post-cancer body might be considered 'less feminine' or 'incomplete' (Grogan et al., , p. 1374. Further, correlational analyses conducted in cross-sectional research has also identified a negative association between internalisation of appearance ideals and body appreciation in a breast cancer population (Lewis-Smith et al., 2020). As highlighted by the present study, distancing oneself from appearance ideals may in turn reduce the likelihood of internalising them; and thus, protect from experiencing body image concerns. Further understanding of the relationship between perceptions and internalisation of appearance ideals in a breast cancer population will help inform knowledge of protective factors for these women.
Age (i.e., growing older) was also deemed a protective factor against internalisation of appearance ideals; which focus on youth among other aspects (e.g., thinness, smooth skin; Buote et al., 2011). Objectification theory argues that women are at greater risk of being sexually objectified when they are younger, during their reproductive years (Fredrickson & Roberts, 1997); and this has been supported by empirical findings (Tiggemann & Lynch, 2001). As women age, they may experience reduced pressure to adhere to a narrow set of appearance ideals and may instead be able to appreciate their body for aspects of its functionality instead (Alleva & Tylka, 2020). Body conceptualisation theory (Franzoi, 1995) differentiates two perspectives on how the body can be viewed: body-as-object (physical appearance) and body-as-process (functionality). This theory proposes that individuals hold more positive attitudes when they adopt the body-as-process perspective. Appreciation of functionality over physcial appearance was a prevelant and salient theme for many women in the present research. Further, in addition to the expected physical changes associated with ageing, women in the present study had experienced potentially life threatening health-realted concerns. Thus, this group may be even further removed from internalising appearance ideals in favour of valuing their health and functionality.
Another common experience described in the present research related to women prioritising their own needs through the adoption of a caring and self-compassionate approach. This finding aligns with aspects of positive embodiment, as proposed by the developmental theory of embodiment (Piran & Teall, 2012). One aspect believed to contribute to positive embodiment is attunement to the body's cues, needs and desires. This awareness and responsiveness to the body's needs was described by women in the present study. Additionally, these findings mirror those identified amongindividuals with spinal cord injuries, where the practice of self-care behaviours to preserve and enhance functionality was deemed an important aspect of positive body image Bailey et al., 2015). Interestingly, it has been suggested that enhanced functionality can be related to a sense of greater agency in the body, which is a protective factor of positive embodiment (Piran & Teall, 2012). Consequently, women in the present study who were responsive to their body's needs through acts of self-care and compassion could have benefitted from maintained or enhanced functionality, which may in turn have contributed to their appreciation for their body.
Further, there is evidence for the protective effect of self-compassion against body dissatisfaction within breast cancer populations. A study conducted with nearly 300 breast cancer survivors found that lower self-compassion mediated the relationship between body dissatisfaction and psychological distress (Przezdziecki et al., 2013). Additionally, self-compassion and appearance investment were found to moderate the body image-distress relationship in a study of women who had undergone a nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR; Sherman et al., 2017). Further, self-compassion interventions have also been found to be effective in reducing body image concerns and psychological distress, whilst increasing body appreciation, in women treated for breast cancer (Przezdziecki et al., 2016;Sherman et al., 2018).The present study extends these findings by enhancing our understanding of the role of self-compassion in maintaining positive body image following a variety of treatments for breast cancer. Support from important others was deemed to play an important role in helping to foster positive feelings about the body. This finding provides support for the acceptance model of intuitive eating (Avalos & Tylka, 2006), which posits that if women believe that their body is accepted by others, they are able to develop a holistic appreciation of the body; based on appreciation of functionality rather than appreciation of appearance alone. This is supported by previous findings which suggest that the degree of emotional and physical satisfaction with intimate contact from another person predicts resilience to body image concerns in women who have undergone a mastectomy (Izydorczyk et al., 2018). Further, similar to the practice of self-care to enhance function, women in the present study also valued practical and emotional support from family and friends, which allowed them to rest, heal and regain functionality. As with self-care, this may have contributed to their feeling of appreciation for their post-treatment bodies. Therefore, close relationships with others who accepted their altered appearance may have provided women with an opportunity to develop a more holistic appreciation of their bodies. This highlights the importance of having an accepting support network both during and following treatment, and ensuring that women are given the opportunity to regain health and functionality; as this will help to affirm positive feelings regarding the body.
Women in the present study prioritised the functionality of their bodies over its physical appearance in a number of ways: valuing health, survival and restored functionality. This finding is similar to that of research with other populations with chronic illness or physical disability. Research in this area has found that an increased focus on what the body can do and gains in functionality, rather than any restrictions cause by a condition or injury, can leads to improved body image (Alleva et al., 2018;Bailey et al., 2015). The findings of the present study also support and extend findings from a qualitative study conducted with women who had undergone a mastectomy . Researchers found that women were focussed on the 'removal' of the cancer and considered the aesthetic changes a secondary concern. In the present study, women also described appreciation of the strength and resilience that their bodies had demonstrated during treatment. This is similar to previous findings from a mixed sample of four breast and bowel cancer survivors, which also indicated an increased trust and respect for their bodies following cancer treatment .This suggests that moving the focus from appearance to health and function may be beneficial in alleviating body image distress for women who have been treated for breast cancer.
Women in this study also talked about their appreciation of the body's ability to carry out valued actions (e.g., hobbies, family life) that are important to daily life and self-identity. This mirrors previous findings among Swedish men and women in the general population (Kling et al., 2018). The developmental theory of embodiment emphasises the importance of engaging in enjoyable physical activities to experience positive embodiment (Piran & Teall, 2012). One of the bodily functions which was considered important to self-identity in the present study was childbearing and the ability to breast feed. . Notably, women also reflected on the likelihood that they would have experienced distress had they not had children prior to their diagnosis, due to concerns over this compromised aspect of body functionality. This suggests that younger women may be more vulnerable to experiencing concerns relating to body functionality and body image distress, particularly if they have not yet had the opportunity to have children. This is consistent with previous findings concerning experiences of fertility changes following breast cancer (Perz et al., 2014). The researchers found that women who were closer to natural menopause age or had completed their families reported being accepting of their bodily changes and fertility status. Consequently, it is important that clinicians supporting women with breast cancer are aware of the potential impact fertility changes may have on perception of body functioning and how this may be linked to identity in women hoping to have children.
Throughout the themes of the present findings, appreciation of body functionality has been considered a key aspect of experiencing a positive relationship with one's post-treatment body. Women described feeling appreciative of their health and their body's functionality; referring to actions and activities in which their bodies had allowed them to engage both prior to and following treatment for breast cancer. These findings lend support to theorised models of positive body image (e.g., the holistic model of body image, Wood-Barcalow et al., 2010; acceptance model of intuitive eating; Avalos & Tylka, 2006 ) which propose that appreciating the unique functionality of one's body is an important characteristic of positive body image. To the authors' knowledge, this is the first qualitative study to explore the concept of body functionality in a breast cancer population, in the context of body image. As such, these findings have important theoretical implications for body image in women who have received treatment for breast cancer.
Whilst the present study makes a valuable contribution to the field, it is important to acknowledge its limitations. First, whilst research exploring positive body image is growing, the associated theoretical models currently lack empirical investigation and support, unlike other more established models of body image (e.g., the Tripartite Influence Model; Thompson et al., 1999). Nonetheless, existing research, including the present qualitative findings, has supported relationships proposed within the models (Avalos & Tylka, 2006;Cash et al., 2005), thus lending support to the theories.
A second limitation pertains to the homogenous sample; whereby the majority of participants were of white ethnicity and resided in the United Kingdom. Existing research highlights that appearance ideals vary between different ethnicities and cultures and are influenced by societal norms, such as differing media messages (Jackson et al., 2020). Therefore, investigating the experience of positive body image among non-white women or women from other cultures would enhance our understanding further. It should also be noted that many of the participants were above 50 years of age and had already had children prior to their cancer diagnosis. However, this is somewhat demographically reflective, as 80% of breast cancer diagnoses occur in women over the age of 50 (Cancer Research UK, 2020). Further, it should be noted that most women in this sample were highly educated and from higher socioeconomic backgrounds. Consequently, it may be that these women had higher financial and social resources (e.g., disposable income to engage in self-care activities, access to private healthcare) to help manage distress related to their altered appearance. As a result, these findings may not be transferable to women from lower socioeconomic backgrounds who may not have access to the same resources. It is also important to note that all women identified as heterosexual and cis gender. It has been found that individuals from the LGBTQ + community can experience inequalities in their healthcare experiences and that there is a need for increased awareness of these issues amongst healthcare professionals (Quinn et al., 2015). Consequently, these findings may not be generalisable to individuals with breast cancer who identify with different sexualities or gender identities. Although the present study provides a promising start for the exploration of positive body image in women with breast cancer, further research is necessary to understand experiences among more diverse groups and women with broader range of recovery experiences. The body image field, as a whole, would also benefit from exploration of positive body image in other appearance-altering conditions (e.g., cleft lip and palate, burns), in order to address the current lack of research in this area.
Despite these limitations, the present study is the first to specifically explore positive body image among breast cancer survivors within a field that has been dominated by research concerning negative aspects of body image. Consequently, the findings of this study contribute new knowledge to the body image and breast cancer literature. The present study has indicated psychosocial factors that may be important in fostering positive body image among breast cancer survivors. Health professionals can utilise this information to better understand the experiences of women who have received treatment for breast cancer and apply this to their usual care of this clinical group. Finally, the present findings provide support for theorised models of positive body image, such as the theory of body appreciation (Avalos et al., 2005) and the holistic model of body image (Wood-Barcalow et al., 2010).
With regard to future avenues for research, positive body image should be explored among more diverse samples of breast cancer survivors, in relation to age, sexuality, ethnicity, sociocultural background, and treatment pathway. Further, whilst the present study focused on women who had already undergone treatment at one timepoint, future research might consider following women from diagnosis to treatment and beyond. Although prior studies have adopted this prospective approach to explore body dissatisfaction (e.g., Wilkins et al., 2000), examining the trajectory and predictors of positive body image would enhance our understanding of adjustment to treatment-related bodily and appearance changes. Relatedly, the use of ecological momentary assessment may shed greater light on in-the-moment influences (e.g., self-compassion) which protect against body dissatisfaction and promote positive body image among women treated for breast cancer (Fuller-Tyszkiewicz, 2019). Finally, innovative visual methods, such as photo-elicitation, could be employed across the treatment trajectory and beyond. The use of personal photographs can help to elicit sharing of experiences and feelings related to the body (Frith & Harcourt, 2007), and might provide in-depth insight into the experiences of, and journeys to, positive body image after breast cancer treatment.

Conclusions
The aim of the present study was to explore the experience of positive body image among women who have undergone treatment for breast cancer. The themes identified suggest several psychosocial factors that may contribute to the experience positive body image in the population. These include resistance to or distancing from the pressures of narrow appearance ideals, the practice of self-care and self-compassion, perceived acceptance of their post-treatment bodies from important others, emotional and practical social support, and focusing on the body in relation to its functionality and health. These findings are consistent with theories of positive body image in the general population and provide implications for future theory, research and practice.