{"paper_id":"2f5904c5-e6a6-40b0-9fb8-385aa408751f","body_text":"Impact of Body Image Perception on Behavioral Outcomes in Chinese Adolescent and Young Adult Survivors of Sarcoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Body Image Perception on Behavioral Outcomes in Chinese Adolescent and Young Adult Survivors of Sarcoma Yihui Wei, Chung Tin Ma, Michael Can Heng Li, Keary Rui Zhou, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3847610/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To identify the prevalence and predictive factors of body image dissatisfaction among Chinese adolescent and young adult (AYA) survivors of sarcoma, and to evaluate its associations with behavioral outcomes. Methods In total, 116 AYA survivors (48.3% female; mean age 28.2 years, SD = 8.2 years) of osteosarcoma (49.1%) or soft-tissue sarcoma (50.9%) were recruited from an academic hospital. The survivors self-reported their perceived body image using the Body Image Scale. Behavioral outcomes were assessed using DSM-oriented scales of the ASEBA Adult Self-Report checklist. Multivariable linear regression was conducted to identify predictors of body image perception and investigate the association between body image dissatisfaction and behavioral outcomes. Results At 15 years post-cancer diagnosis, one third of the cohort (35.3%) reported dissatisfaction with their body image. Female survivors (Est = 3.13, SE = 1.53; P = 0.044) and survivors who had undergone surgery (Est = 7.13, SE = 3.35; P = 0.037) reported poorer body image perception. Body image dissatisfaction was associated with symptoms of depression (Est = 0.29, SE = 0.10; P = 0.005) and avoidant personality (Est = 0.41, SE = 0.12; P < 0.001). Conclusion A negative perception of body image was associated with psychological distress in long-term survivorship. The provision of psychosocial intervention early during the cancer care continuum may mitigate the negative impact of body image distress in AYA survivors. Adolescents and young adults sarcoma survivors body image dissatisfaction behavioral outcomes Figures Figure 1 Figure 2 Introduction Osteosarcoma and soft tissue sarcoma (STS) are relatively rare cancers among adolescents and young adults (AYAs). Improved treatment strategies for childhood osteosarcoma and STS that involve surgery, chemotherapy and radiation have led to increased survival rates [ 1 , 2 ]. However, survivorship comes at the cost of developing myriad adverse effects that can affect the survivor’s quality of life and functional outcomes later in life [ 1 ]. The cancer experience and long-term side effects of treatment require major readjustments to survivors’ physical and role functioning, as well as to their social and interpersonal relationships. Due to intensive surgical and radiological treatments, survivors of certain solid tumors may experience body image dissatisfaction and negative body changes such as scarring, amputation, and disfigurement, and these issues may persist into long-term survivorship [ 3 ]. Most studies on body image concerns have been conducted in adult patients with breast, head and neck, and gynecological cancers [ 4 – 7 ]. Much less attention has been paid to body image concerns among survivors of sarcoma. Embarrassment and concerns about their altered physical appearance were common themes identified in a qualitative study on sarcoma survivors’ perspectives on their body image after resection/limb salvage surgery [ 8 ]. One recent study also showed that patients with bone tumors reported worse scores than healthy controls for physical categories of quality of life, as well as for functional and aesthetic aspects of body image [ 9 ]. This may reflect persistent body image concerns and negative perceptions of physical changes among survivors of sarcoma, especially those with scars or highly visible disfigurement. AYAs with cancer may be particularly vulnerable to body image disturbance, as they are often affected by sociocultural factors such as peer pressure and media influence [ 10 , 11 ]. When negative perceptions of body image are internalized, they may manifest as behavioral problems, such as social withdrawal, anxiety, and depression, during survivorship [ 12 , 13 ]. Among adult survivors of childhood cancer, it has been reported that body image dissatisfaction mediates the association between treatment-related scarring/disfigurement and psychological distress, regardless of sex [ 13 ]. From a developmental perspective, the impact of scarring and/or disfigurement may be particularly detrimental when it is acquired in or persists through adolescence and young adulthood, because these periods are critical for establishing social and sexual identities. Currently, most reports of body image perception in AYA survivors of cancer relate to Western populations. Considering the significant role of culture in shaping appearance ideals, it is important to examine the impact of body image on behavioral problems in young Chinese survivors of sarcoma. The objectives of this study were (1) to identify clinical, treatment, and socioenvironmental factors associated with body image perception in Chinese AYA survivors of sarcoma, and (2) to evaluate the association between body image dissatisfaction and behavioral outcomes. Material and methods Study design This cross-sectional study was conducted between June 2020 and May 2022 at the long-term survivors’ clinics of the Department of Orthopaedics and Traumatology and the Department of Paediatrics of the Prince of Wales Hospital in Hong Kong. Participants who were 18 years old or over were provided with written informed consent. For those who were under 18, written informed consent was provided by their parents. The study was approved by the Institution Review Board of the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee, Hong Kong, China (Ref: 2018.131). The study followed the Declaration of Helsinki ethical principles. Study population Survivors were eligible for the study if they (1) were aged 15 to 39 years old, (2) had been diagnosed with osteosarcoma or STS, and (3) had survived for at least 5 years post-diagnosis and 2 years after completion of cancer treatment. Survivors who had any pre-existing developmental or behavioral disorders were excluded. Body image perception Body image perception was evaluated using the 10-item Body Image Scale (BIS)[ 14 ], which was developed to assess changes in body image in patients with cancer. The scale comprises (1) cognitive items, which relate to the cognitive appraisals individuals make of their appearance (e.g. dissatisfaction with one’s appearance, or with scarring), (2) affective items, which relate to the emotions associated with one’s appearance (e.g. feeling feminine, feeling attractive), and (3) behavioral items, which relate to how individuals behave toward their body (e.g. finding it hard to look at oneself naked, avoiding people because of one’s appearance) [ 14 ]. Each item is assessed using a 4-point scale from “not at all” to “very much”. The BIS has been widely used as a tool to evaluate body image perception in diverse populations of cancer patients, and it has strong evidence supporting its structural validity, internal consistency, and reliability. The Chinese version of the BIS has been tested in Chinese patients with nasopharyngeal cancer [ 15 ]. A higher score is indicative of higher dissatisfaction with body image. Patients who reported a total score of > 10 points are categorized as “dissatisfied with their body image” [ 7 , 16 – 18 ]. Behavioral outcomes Behavioral functioning was evaluated using the traditional Chinese version of the Achenbach System of Empirically Based Assessment (ASEBA) Adult Self-Report (ASR) checklist [ 19 ]. The primary outcomes of interest were the DSM-oriented scales for Depressive Problems, Anxiety Problems, Somatic Problems, Avoidant Personality Problems, Attention Deficit/Hyperactivity (AD/H) Problems (Inattention and Hyperactivity/Impulsivity subscales), and Antisocial Personality Problems. The Chinese version of the ASR has been used and validated in the Chinese general population [ 20 ]. Predictors of body image perception Predictors of body image perception were determined a priori based on a literature review. Sociodemographic predictors included sex, age at follow-up, highest educational attainment, and employment status [ 4 , 5 , 21 ]. Clinical predictors were cancer diagnosis, age at cancer diagnosis, history of relapse, presence of chronic health conditions, and weight status [ 22 – 25 ]. Treatment predictors included surgery, radiation, and chemotherapy. Both the clinical information and the treatment information were abstracted from the Clinical Management System, an electronic health data repository of the public healthcare system in Hong Kong. The focal behavioral predictors were family functioning and physical activity. Family functioning was assessed using the validated Chinese Family Assessment Instrument (CFAI)[ 26 , 27 ]. The CFAI is a 33-item tool that measures the domains of mutuality, communication and cohesiveness, conflict and harmony, parental concern and parental control. The item scores are summed to yield total scores ranging from 33 to 165, and a higher score represents poorer family functioning. The participants self-reported their physical activity level using the validated Chinese University of Hong Kong: Physical Activity Rating for Children and Youth (CUHK-PARCY)[ 28 , 29 ], which uses an 11-point scale (0 to 10) to evaluate the level, intensity and frequency of physical activity based on the metabolic equivalent of task score. The CUHK-PARCY has been validated and has been used to measure physical activity in Chinese survivors of childhood cancer [ 29 , 30 ]. A score of 0–3 is regarded as indicating a low activity level, while 4–6 represents moderate activity and 7–10 indicates a high activity level. Statistical analysis The sample characteristics and outcome measures were summarized using descriptive statistics for the overall cohort and stratified by body image perception. The Mann–Whitney U test or Kruskal–Wallis test (for continuous variables) and chi-square test (for categorial variables) were used to compare the sociodemographic, clinical, and behavioral characteristics of survivors who were satisfied versus dissatisfied with their body image. General linear modelling was conducted to evaluate the association between survivors’ characteristics and BIS scores. For behavioral outcomes, a one-sample t -test was used to compare the survivors’ performance with the normative data ( t -score = 50), correcting for false discovery rate [ 31 ]. General linear modeling was conducted to identify the factors associated with behavioral outcomes, adjusting for clinically relevant covariates that are associated with behavioral outcomes in survivors of cancer: age, sex, cancer diagnosis, surgery, radiation, and weight status [ 5 , 12 , 32 ]. Unstandardized point estimates (Est) and standard errors (SE) were used to quantify the effect size of the associations. Results Characteristics of study cohort A total of 116 survivors were enrolled in the study (Table 1 ). The average age at evaluation was 28.2 (SD = 8.2) years, and 48.3% were female. Approximately half of the survivors (50.9%) had been diagnosed with STS and 57 (49.1%) had been diagnosed with osteosarcoma. The average length of time since diagnosis was 14.9 (SD = 7.6) years. A minority (10.3%) had experienced a relapse and almost half (46.9%) had developed chronic health conditions. Most of the survivors had received surgery (95.7%) or chemotherapy (91.9%). The majority of the osteosarcoma survivors had received tumor resection with prosthesis (35.7%) or allograph reconstruction (17.9%), while the majority of the STS survivors had received local tumor resection (43.7%). The mean BMI was 21.7 kg/m 2 (SD = 3.9). Nearly a quarter (23.3%) of the survivors were overweight or obese, and 13.8% were underweight. Table 1 Characteristics of Overall Participants and Grouped by Satisfaction of Body Image Characteristics Overall n = 116 Dissatisfied n = 41 Satisfied n = 75 P n (%) n (%) n (%) Sex 0.93 * Male 60 (51.7) 21 (51.2) 39 (52.0) Female 56 (48.3) 20 (48.8) 36 (48.0) Age at Interview mean [SD] 28.2 [8.2] 31.0 [6.9] 26.7 [8.5] 0.001 # >15–18 years 13 (11.2) 1 (2.4) 12 (16.0) ≥18–30 years 58 (50.0) 15 (36.6) 43 (57.3) >30 years 45 (38.8) 25 (61.0) 20 (26.7) Age of cancer diagnosis mean [SD] 13.3 [7.2] 14.7 [5.7] 12.5 [7.9] 0.032 # < 15 years 76 (65.5) 26 (63.4) 50 (66.7) ≥15–20 years 27 (23.3) 11 (26.8) 16 (21.3) ≥20–30 years 8 (6.9) 3 (7.3) 5 (6.7) >30 years 5 (4.3) 1 (2.4) 4 (5.3) Years From Diagnosis mean [SD] 14.9 [7.6] 16.3 [7.1] 14.2 [7.8] 0.076 # ≤5 years 16 (13.8) 6 (14.6) 10 (13.3) >5–10 years 16 (13.8) 2 (4.9) 14 (18.7) >10–20 years 53 (45.7) 19 (46.3) 34 (45.3) >20 years 31 (26.7) 14 (34.2) 17 (22.7) Education Level 0.080 * Secondary school or below 42 (37.5) 10 (26.3) 32 (43.2) Post-secondary school or above 70 (62.5) 28 (73.7) 42 (56.8) Employment Status 0.025 * Employed 81 (69.8) 35 (85.4) 46 (61.3) Not employed 20 (17.2) 3 (7.3) 17 (22.7) Students 15 (13.0)) 3 (7.3) 12 (16.0) Clinical characteristics Cancer 0.26 * Soft-tissue sarcoma 59 (50.9) 18 (43.9) 41 (54.7) Osteosarcoma 57 (49.1) 23 (56.1) 34 (45.3) Subtypes (for soft-tissue sarcoma only) N.A. Rhabdomyosarcoma 5 (8.5) 2 (11.1) 3 (7.3) Ewing sarcoma 11 (18.6) 4 (22.2) 7 (17.1) Liposarcoma 2 (3.4) 1 (5.6) 1 (2.4) Synovial Sarcoma 5 (8.5) 2 (11.1) 3 (7.3) Clear Cell Sarcoma 4 (6.8) 0 4 (9.8) PNET 3 (5.1) 0 3 (7.3) Others 29 (49.1) 9 (50.0) 20 (48.8) Tumor site (for soft-tissue sarcoma) N.A. Lower extremity 18 (30.5) 5 (27.8) 13 (31.7) Upper extremity 6 (10.2) 3 (16.7) 3 (7.3) Abdomen/pelvis 17 (28.8) 5 (27.8) 12 (29.3) Head and neck 10 (16.9) 1 (5.5) 9 (21.9) Chest 8 (13.6) 4 (22.2) 4 (9.8) Tumor site (for osteosarcoma) Femur 32 (56.1) 15 (65.2) 17 (50.0) Tibia 14 (24.5) 2 (8.7) 12 (35.3) Humerus 5 (8.8) 4 (17.4) 1 (2.9) Fibula 3 (5.3) 1 (4.4) 2 (5.9) Others 3 (5.3) 1 (4.3) 2 (5.9) Relapse 0.26 * No 104 (89.7) 35 (85.4) 69 (92.0) Yes 12 (10.3) 6 (14.6) 6 (8.0) CHCs 0.48 * No 60 (53.1) 20 (48.8) 40 (55.6) Yes 53 (46.9) 21 (51.2) 32 (44.4) Body mass index mean [SD] 21.7 [3.9] 23.0 [4.9] 20.8 [2.8] 0.032 # Underweight 16 (13.8) 7 (17.1) 9 (12.0) Normal 73 (62.9) 19 (46.3) 54 (72.0) Overweight/obese 27 (23.3) 15 (36.6) 12 (16.0) Treatment characteristics Chemotherapy 0.47 * No 21 (18.1) 6 (14.6) 15 (20.0) Yes 95 (91.9) 35 (85.4) 60 (80.0) Radiation 0.69 * No 78 (68.4) 29 (70.7) 49 (67.1) Yes 36 (31.6) 12 (29.3) 24 (32.9) Surgery 0.13 * No 4 (3.4) 0 4 (5.3) Yes 112 (96.6) 41 (100) 71 (94.7) 0.077 *^ Amputation 3 (2.7) 3 (7.3) 0 Resection with allograph reconstruction 20 (17.9) 8 (19.5) 12 (16.9) Resection with prosthesis 40 (35.7) 16 (39.0) 24 (33.8) Resection (other sites) 49 (43.7) 14 (34.1) 35 (49.3) Lobectomy due to metastatic tumor 11 (9.8) 7 (17.1) 4 (5.6) Treatment combinations 0.44 * Surgery only 14 (12.1) 4 (9.7) 10 (13.3) Surgery and chemotherapy 63 (54.3) 25 (61.0) 38 (50.7) Surgery, chemotherapy and radiation 27 (23.3) 10 (24.4) 17 (22.7) Others 12 (10.3) 2 (4.9) 10 (13.3) Behavior characteristics Family functioning mean [SD] 89.1 [14.8] 92.7 [13.1] 87.0 [15.3] 0.034 # Physical activity mean [SD] 4.3 [2.8] 4.1 [2.9] 4.5 [2.8] 0.50 # Low level (0 to 3 points) 50 (43.1) 21 (51.2) 29 (38.7) Moderate level (4 to 6 points) 40 (34.5) 11 (26.8) 29 (38.7) High level (7 to 10 points) 26 (22.4) 8 (22.0) 17 (22.6) CHC: chronic health condition; N.A.: Not applicable (comparison was not conducted due to the small sample size); PNET: primitive neuro-ectodermal tumor * Comparison was conducted using Chi-square test between dissatisfied group and satisfied group. # Comparison was conducted using Mann-Whitney U test between dissatisfied group and satisfied group. ^ Comparison was conducted among individuals who received amputation versus resection with allograph versus resection with prosthesis. Boldface indicates statistical significance at P < 0.05. Most of the participants had a level of education higher than secondary school (62.5%) and were employed at the time of the interview (69.8%). The mean CUHK-PARCY score for physical activity was 4.3 (SD = 2.8), indicating a moderate level of physical activity. The mean family functioning score was 89.1 (SD = 14.8). Body image perception The median BIS score was 8 (range = 4–14) and the mean score was 9.4 (SD = 7.1) (Table 2 ). Based on the published cutoffs, the prevalence of body image dissatisfaction was 35.3%. The largest proportion of dissatisfaction was observed on the cognitive subscale (48.3%), followed by the affective subscale (29.3%) and the behavioral subscale (17.2%). Table 2 Body image scale total score and subscale scores Overall n = 116 Dissatisfied with body image * Mean (SD) Median (IQR) n (%) Body image scale (total score) 9.4 (7.1) 8 (4–14) 41 (35.3) Affective subscale score 3.3 (3.2) 2 (1–5.5) 34 (29.3) Behavioral subscale score 1.2 (1.4) 1 (0–2) 20 (17.2) Cognitive subscale score 4.9 (3.3) 4 (3–7) 56 (48.3) SD: standard deviation; IQR: interquartile range * Patients who reported a total score of > 10 points are categorized as “dissatisfied with their body image”. The Affective and cognitive subscale each includes 4 items, with scores ranging from 0 to 12. “Dissatisfaction” was defined as a subscale score > 4 points. The Behavioral subscale includes 2 items, with score ranging from 0 to 6. “Dissatisfaction” was defined as a subscale score > 2 points. Details of the participants’ body image perception are presented in Fig. 1 . Approximately one third of the survivors reported dissatisfaction with their appearance. Among the affective items, survivors reported most concern about being “less physically attractive” (34.5%) and “less wholesome” (31%); 40.5% reported that they felt “self-conscious” about their appearance. Only 8.7% of the survivors were quite or very concerned about seeing themselves naked. Comparison of characteristics of participants with versus without body image dissatisfaction The demographic, clinical, treatment, and behavioral characteristics of survivors who were satisfied and dissatisfied with their body image are compared in Table 1 . Compared with survivors who were satisfied with their body image, survivors who were dissatisfied were older both at interview (mean = 31.0 years, SD = 6.9 years versus mean = 26.7 years, SD = 8.5 years, respectively; P = 0.001) and at cancer diagnosis (mean = 14.7 years, SD = 5.7 years versus mean = 12.5 years, SD = 7.9 years, respectively; P = 0.032). The proportion of the dissatisfied group in full-time employment was larger than that of the satisfied group (85.4% versus 61.3%; P = 0.025). Survivors with body image dissatisfaction also had a higher BMI than those who reported satisfaction (mean = 23.0, SD = 4.9 kg/m 2 versus mean = 20.8, SD = 2.8 kg/m 2 ; P = 0.032). Survivors with body image dissatisfaction reported higher total CFAI scores (mean = 92.7, SD = 13.1 versus mean = 87.0, SD = 15.3; P = 0.044), indicating relatively poor family functioning in the dissatisfied group. The two groups did not significantly differ in terms of educational attainment, subtype of sarcoma, or level of physical activity. The multivariable analyses showed that the significant risk factors predicting a poorer score on the BIS were being female (Est = 3.015, SE = 1.496; P = 0.047), surgery treatment (Est = 7.414, SE = 3.659; P = 0.046) and worse family functioning (Est = 0.131, SE = 0.051, P = 0.013) (Supplemental Table 1). There was a significant difference in BIS total score when comparing four groups of survivors with different surgery sites (P = 0.042). The three survivors who had undergone amputation reported poorer body image perception (BIS mean score = 19.3, SD = 4.0) than those who had received other types of surgeries (Supplemental Table 2). Behavioral outcomes in the overall cohort Compared with the reference norm (mean = 50, SD = 10), the participants in our study demonstrated poorer outcomes in all measured behavioral domains (Fig. 2 ). A minority reported impairment from depressive problems (13.8%), anxiety (4.3%), somatic problems (6.0%), avoidant personality problems (6.9%), AD/H problems (6.0%) and antisocial problems (6.0%). The mean scores and impairment rates for behavioral measures in the study cohort, and in participants who reported dissatisfaction or satisfaction with their body image perception, are shown in Supplemental Table 3. Compared with survivors who were satisfied with their body image, survivors in the dissatisfaction group reported significantly more depressive problems (P = 0.004), anxiety problems (P < 0.001), somatic problems (P = 0.014), avoidant personality problems (P = 0.002) and AD/H problems (P = 0.037). No differences were found between the groups for the other behavioral outcome scores. Association between body image perception and behavioral outcomes After adjusting for age at interview, sex, type of cancer diagnosis, treatment modalities and weight status, the multivariate analyses showed that higher BIS total scores were associated with more depressive problems (Est = 0.29, SE = 0.10; P = 0.005), anxiety problems (Est = 0.38, SE = 0.12; P = 0.002) and avoidant personality problems (Est = 0.41, SE = 0.12; P < 0.001) (Table 3 ). Table 3 Association between Body Image Satisfaction and Behavioral Outcomes Depressive problems* Anxiety problems* Somatic problems* Avoidant personality problems* Attention Deficit/ Hyperactivity Problems* Antisocial personality* Est SE P Est SE P Est SE P Est SE P Est SE P Est SE P Body image scale (total score) 0.29 0.10 0.005 0.38 0.12 0.002 0.22 0.12 0.066 0.41 0.12 < 0.001 0.19 0.12 0.113 0.17 0.13 0.206 Affective subscale score 0.11 0.05 0.015 0.18 0.05 0.002 0.08 0.05 0.122 0.17 0.05 0.002 0.06 0.05 0.275 0.05 0.06 0.402 Behavioral subscale score 0.61 0.02 0.003 0.05 0.03 0.050 0.05 0.02 0.053 0.08 0.02 < 0.001 0.05 0.02 0.037 0.05 0.03 0.039 Cognitive subscale score 0.11 0.04 0.013 0.16 0.05 0.005 0.09 0.05 0.087 0.15 0.05 0.005 0.08 0.05 0.125 0.06 0.06 0.281 Est: estimate; SE: standard error * A higher score was indicative of worse functioning. All models were adjusted for age, sex, cancer diagnosis, surgery, radiation, and weight status. Boldface indicates statistical significance at P < 0.05. The subscales analyses showed that poorer body image perception in the behavioral domain was significantly associated with more depressive problems (Est = 0.61, SD = 0.02; P = 0.003), avoidant personality problems (Est = 0.08, SE = 0.02; P < 0.001), AD/H problems (Est = 0.05, SE = 0.02; P = 0.037), and antisocial personality problems (Est = 0.05, SE = 0.03; P = 0.039). Discussion This is the first study investigating body image dissatisfaction and its associated factors among Chinese survivors of sarcoma. Over one third of the Chinese AYA survivors of sarcoma in the study reported dissatisfaction with their body image. Female (vs. male) participants and those who had (vs. those who had not) undergone surgery were more likely to have concerns about their appearance. Higher rates of behavioral problems were found among the participants compared with population norms. Importantly, poor body image perception was associated with more significant internalizing symptoms of depression, anxiety, and avoidant personality. Our findings highlight the challenges of body image perception for Chinese AYAs with cancer, and suggest that advocacy efforts aimed at improving the body image of young people in Hong Kong are critically needed. Body image can be considered a potential modifiable risk factor to address psychological symptoms in the Chinese population, which could inform future psychological interventions focused on improving body image perception among AYA survivors with sarcoma. Body image changes are a major psychosocial concern and a key determinant of decreased quality of life among cancer survivors [ 1 , 33 , 34 ], which can lead to difficulties with self-awareness and peer pressure [ 35 ], especially among AYAs [ 36 , 37 ]. The participants in our study who had undergone surgery reported worse body image perceptions, which is consistent with earlier research. For example, one qualitative study reported that sarcoma survivors described altered appearances and impaired self-esteem after surgical treatment, which made them feel unattractive and more sensitive to staring and reactions from other people [ 38 ]. Body image concerns may be more relevant to survivors of sarcoma compared with other types of cancer because they typically receive extensive resection of tumor sites in parts of the body that are visible. We found that survivors who had undergone amputation reported poorer body image perception than those who had received other types of surgeries. Fortunately, most patients with osteosarcoma or STS in upper or lower extremities can now be treated with limb-salvage surgery, which has less impact on patients’ daily activities compared with limb amputation [ 39 , 40 ]. However, the use of a prosthesis may still affect limb functioning, resulting in limited movement and disfiguration. Importantly, we did not find significant differences in body image perception among osteosarcoma survivors who had received tumor resection with allograft reconstruction versus prosthesis, and studies have shown that the former approach is associated with substantially improved functional outcomes [ 41 , 42 ]. Our findings reinforce the need for holistic care for survivors of sarcoma; in addition to examining the health status and functional limitations of sarcoma survivors, long-term follow-up consultations should include questions about body image and mobility to better identify survivors who need psychological assistance. As previously noted, we found that one third of the survivors (35.3%) were not satisfied with their body image. In the literature, the proportion of body image dissatisfaction ranges from 13–28% among patients with head and neck cancer, breast cancer, and brain tumors in North America and Europe [ 4 , 6 , 22 , 43 ]. However, relatively few studies have been conducted in Asian populations. One Korean study reported that 39.3% of survivors of hematological malignancies reported body image dissatisfaction [ 44 ]. Cultural differences play an important role in disparities in body image perception, as perceptions of body shape and beauty are often influenced by social expectations and societal norms. A cross-cultural study found more body image concerns among both female and male adolescents from Malaysia and China than those from Australia, particularly regarding weight, body shape, hair, and extremities [ 45 , 46 ]. Studies have shown that Asians are more likely to feel distressed by and anxious about deviating body features, even when the differences are hardly noticeable. For example, normal weight and underweight Asian women had a tendency to view themselves as overweight [ 47 , 48 ]. Consistent with the literature [ 5 , 12 , 22 , 49 ], our study found that females were more likely to be self-conscious about their altered appearance. Our univariate analysis also found a larger proportion of overweight/obese individuals in the dissatisfied group than the satisfied group, possibly because survivors of osteosarcoma may have problems engaging in strenuous exercise. Applying the study findings to the local context, partnership with non-governmental organizations (NGOs) may help survivors reconstruct their confidence and acquire social skills during cancer survivorship. As osteosarcoma survivors with amputation or prosthesis or previous lobectomy due to tumor metastasis might not be able to engage in strenuous activities, light physical activities like yoga, Qigong and Taiji under professional guidance can both enhance vitality and strengthen overall health in this cohort [ 50 ]. Considering the multiple positive outcomes associated with physical activity, encouraging survivors to engage in existing exercise programs offered by local NGOs and academic institutions may also improve survivors’ self-esteem and body image. Consistent with the literature, we found significantly higher rates of behavioral problems in the overall cohort of sarcoma survivors compared with population norms. Participants with body image dissatisfaction demonstrated worse depression, anxiety, and avoidant personality problems than those who did not express concerns about their body image. This finding reveals the detrimental impact of negative body image perceptions on survivors’ internalizing behaviors. AYA patients may experience negative emotional reactions due to unexpected cancer-related body changes [ 37 ]. Body image dissatisfaction on the cognitive subscale was strongly associated with internalizing behavioral symptoms, suggesting that many patients have a distorted perception of their appearance that manifests as avoidance and social anxiety even years after completion of cancer treatment. The intrinsic thoughts and beliefs that patients hold about their body and their subjective feelings about their appearance may mediate the relationship between the cancer experience and emotional distress. However, changes in appearance may not always lead to negative sequelae [ 51 ]; a change can contribute to mental resilience when appraised in a positive light. For example, acceptance of changes in appearance and engagement in self-care are associated with resilience and positive illness perception in Asian women with breast cancer [ 52 ]. Such positive changes are in line with theoretical conceptualizations of posttraumatic growth in response to negative life events [ 53 ]. Future work should explore the mediating role of body image in illness perception and resilience, and implement interventions early, before distress develops into significant psychological problems that affect patients’ functional outcomes. We also found that dissatisfaction on the behavioral subscale was associated with avoidant personality problems and antisocial personality, suggesting worse interpersonal functioning. Body image concerns may affect survivors’ social and intimate relationships, resulting in avoidance and alienation from peers [ 1 , 54 ]. Our study also showed that poor family functioning was associated with negative body image perception. Interestingly, one study reported that among the different sources of social support (family, friends, and significant others), only support from friends significantly mediated the association between body image distress and depressive symptoms in patients with cancer [ 55 ]. Peer support groups allow survivors to openly share, discuss, and encourage each other for resilience and self-acceptance, which can further help reduce appearance-related anxiety [ 56 ]. Collectively, these findings support leveraging survivors’ existing social network to improve their perception of body image and their interpersonal relationships. For example, adolescent survivors of osteosarcoma often need special assistance when they return to school after treatment [ 57 ]; peer support and buddy programs may help to provide a supportive social environment and improve mental health outcomes as patients transition into survivorship. Our study has several limitations. First, causal and temporal relationships between body image perception and behavioral symptoms cannot be established, due to the cross-sectional design of the study. It is likely that body image perception and behavioral symptoms co-exist and can interact with each other. The mechanism of associations between body image dissatisfaction and behavioral outcomes requires prospective investigation throughout the cancer care continuum from diagnosis to long-term survivorship. Second, our results are limited by the absence of a non-cancer control group. However, the impact of cancer on body image perception has been extensively reported in the literature [ 58 ]. Therefore, the risk factor analysis and the associations between body image and behavioral outcomes might still be valid and applicable to the population of AYA cancer survivors. Third, our study population was small and participants were recruited from a single public hospital. However, survivors of osteosarcoma and STS who are treated in the public healthcare system in Hong Kong typically receive standard treatment protocols that are similar to other developed countries. Hence, it is reasonable to assume that our findings might be generalizable to other AYA survivors of sarcoma in Hong Kong, and can also provide a foundation for further studies in other Asian countries or regions. Conclusions Our study provides important perspectives on the evidence of body image distress in long-term survivors of sarcoma. Negative perception of body image was associated with depression, anxiety and avoidant personality problems. Disparities in body image dissatisfaction between Asian and Western populations offer insight into cultural differences. Future research should focus on identifying survivors who are at risk of experiencing negative body image perception and implementing psychological interventions specifically focused on addressing body image dissatisfaction in AYA survivors of sarcoma. The provision of social support and psychosocial intervention early during the cancer care continuum may mitigate the negative impact of body image distress in AYA survivors. Declarations Fundings This study is funded by the Hong Kong Research Grant Council, General Research Fund (Ref: 14601919). Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by YT, CT, HF, KC, CK. Data analysis was performed by YH and YT. The first draft of the manuscript was written by YH and YT and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This is an observational study. The study was approved by the Institution Review Board of the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee, Hong Kong, China (Ref: 2018.131). The study followed the Declaration of Helsinki ethical principles. Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish The authors affirm that human research participants provided informed consent for publication of the Tables 1, 2 and 3, and images in Figures 1 and 2. References Janssen, S.H.M., et al., Adolescent and Young Adult (AYA) Cancer Survivorship Practices: An Overview. Cancers (Basel), 2021. 13 (19). Close, A.G., et al., Adolescent and young adult oncology-past, present, and future. CA Cancer J Clin, 2019. 69 (6): p. 485-496. Fingeret, M.C., I. Teo, and D.E. 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Belle, F.N., et al., Body image in adolescent survivors of childhood cancer: The role of chronic health conditions. Pediatr Blood Cancer, 2022. 69 (11): p. e29958. Ribeiro, F.E., et al., Body dissatisfaction and its relationship with overweight, sedentary behavior and physical activity in survivors of breast cancer. Eur J Obstet Gynecol Reprod Biol, 2018. 229 : p. 153-158. Siu, A.M. and D.T. Shek, Psychometric properties of the Chinese Family Assessment Instrument in Chinese adolescents in Hong Kong. Adolescence, 2005. 40 (160): p. 817-830. Shek, D.T.L., Assessment of family functioning in chinese adolescents: The chinese family assessment instrument , N.N. Singh, T.H. Ollendick, and A.N. Singh, Editors. 2002, Elsevier. p. 297-316. Kong, A.P., et al., Association between physical activity and cardiovascular risk in Chinese youth independent of age and pubertal stage. BMC public health, 2010. 10 : p. 303-303. Li, H.C., et al., The impact of cancer on the physical, psychological and social well-being of childhood cancer survivors. European journal of oncology nursing : the official journal of European Oncology Nursing Society, 2013. 17 (2): p. 214-219. Peng, L., et al., Neurocognitive and Behavioral Outcomes of Chinese Survivors of Childhood Lymphoblastic Leukemia. Front Oncol, 2021. 11 : p. 655669. Benjamini, Y. and Y. Hochberg, Controlling the False Discovery Rate: A Practical and Powerful Approach to Multiple Testing. Journal of the Royal Statistical Society.Series B (Methodological), 1995. 57 (1): p. 289-300. Macias, D., et al., Factors Associated With Risk of Body Image-Related Distress in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg, 2021. 147 (12): p. 1019-1026. Bellizzi, K.M., et al., Positive and negative psychosocial impact of being diagnosed with cancer as an adolescent or young adult. Cancer, 2012. 118 (20): p. 5155-62. Olsson, M., et al., Self-Perceived Physical Attractiveness in Relation to Scars Among Adolescent and Young Adult Cancer Survivors: A Population-Based Study. J Adolesc Young Adult Oncol, 2018. 7 (3): p. 358-366. Shaw, P.H., et al., Adolescent and Young Adult (AYA) Oncology in the United States: A Specialty in Its Late Adolescence. J Pediatr Hematol Oncol, 2015. 37 (3): p. 161-9. Fan, S.Y. and C. Eiser, Body image of children and adolescents with cancer: A systematic review. Body Image, 2009. 6 (4): p. 247-56. Moore, J.B., et al., A qualitative assessment of body image in adolescents and young adults (AYAs) with cancer. Psychooncology, 2021. 30 (4): p. 614-622. Fauske, L., et al., Changes in the body image of bone sarcoma survivors following surgical treatment--A qualitative study. J Surg Oncol, 2016. 113 (2): p. 229-34. American Cancer Society. Surgery for Soft Tissue Sarcomas . 2022 [cited 2022 December 12, 2022]; Available from: https://www.cancer.org/content/dam/CRC/PDF/Public/8816.00.pdf. American Cancer Society. Surgery for Osteosarcoma . 2020 [cited 2020 October 8, 2020]; Available from: https://www.cancer.org/content/dam/CRC/PDF/Public/8771.00.pdf. Savvidou, O.D., et al., Oncological and Functional Outcomes after Hemicortical Resection and Biological Reconstruction Using Allograft for Parosteal Osteosarcoma of the Distal Femur. Sarcoma, 2022. 2022 : p. 5153924. Gharehdaghi, M., et al., Short Term Complications and Functional Results of Sarcoma Limb Salvage Surgeries. Arch Bone Jt Surg, 2019. 7 (2): p. 161-167. Rowe, L., et al., The prevalence of altered body image in patients with primary brain tumors: an understudied population. J Neurooncol, 2020. 147 (2): p. 397-404. Kang, D., et al., Association between body image dissatisfaction and poor quality of life and depression among patients with hematopoietic stem cell transplantation. Support Care Cancer, 2021. 29 (7): p. 3815-3822. Mellor, D., et al., A cross-cultural study investigating body features associated with male adolescents' body dissatisfaction in Australia, China, and Malaysia. Am J Mens Health, 2014. 8 (6): p. 521-31. Mellor, D., et al., Which body features are associated with female adolescents' body dissatisfaction? A cross-cultural study in Australia, China and Malaysia. Body Image, 2013. 10 (1): p. 54-61. Wu, Y., S. Mulkens, and J.M. Alleva, Body image and acceptance of cosmetic surgery in China and the Netherlands: A qualitative study on cultural differences and similarities. Body Image, 2022. 40 : p. 30-49. Park, S., J. Shin, and S. Baek, Analysis of Health-Related Behaviors of Adult Korean Women at Normal BMI with Different Body Image Perceptions: Results from the 2013-2017 Korea National Health and Nutrition Examination Survey (KNHNES). Int J Environ Res Public Health, 2020. 17 (15). Zucchetti, G., et al., Body Image Discomfort of Adolescent and Young Adult Hematologic Cancer Survivors. Journal of Adolescent and Young Adult Oncology, 2017. 6 (2): p. 377-380. Hong Kong Cancer Fund. Wellness Program . 2023 [cited 2023 2023]; Available from: https://www.cancer-fund.org/en/our-wellness-programmes-2/#:~:text=Programmes%20include%3A%20The%20Feldenkrais%20Method%20and%20Body%20Nuance.&text=Pilates%20is%20a%20gentle%2C%20restorative,emphasis%20on%20precision%20and%20control. Kosir, U., et al., Psychological adaptation and recovery in youth with sarcoma: a qualitative study with practical implications for clinical care and research. BMJ Open, 2020. 10 (11): p. e038799. Chiu, H.C., et al., Resilience among women with breast cancer surviving longer than five years: The relationship with illness perception and body image. Eur J Oncol Nurs, 2023. 62 : p. 102254. Tedeschi, R.G. and L.G. Calhoun, TARGET ARTICLE: \"Posttraumatic Growth: Conceptual Foundations and Empirical Evidence\". Psychological Inquiry, 2004. 15 (1): p. 1-18. Bolte, S. and B. Zebrack, Sexual issues in special populations: adolescents and young adults. Semin Oncol Nurs, 2008. 24 (2): p. 115-9. Scandurra, C., et al., Social Support Mediates the Relationship between Body Image Distress and Depressive Symptoms in Prostate Cancer Patients. Int J Environ Res Public Health, 2022. 19 (8). Morales-Sanchez, L., et al., Enhancing Self-Esteem and Body Image of Breast Cancer Women through Interventions: A Systematic Review. Int J Environ Res Public Health, 2021. 18 (4). Yeung, N.C.Y., et al., Transition from Acute Treatment to Survivorship: Exploring the Psychosocial Adjustments of Chinese Parents of Children with Cancer or Hematological Disorders. Int J Environ Res Public Health, 2021. 18 (15). Lehmann, V., M. Hagedoorn, and M.A. Tuinman, Body image in cancer survivors: a systematic review of case-control studies. J Cancer Surviv, 2015. 9 (2): p. 339-48. Additional Declarations No competing interests reported. Supplementary Files Supplinfo.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-3847610\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":266397643,\"identity\":\"240972da-43cb-422b-b042-4bc9d6b3076b\",\"order_by\":0,\"name\":\"Yihui Wei\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yihui\",\"middleName\":\"\",\"lastName\":\"Wei\",\"suffix\":\"\"},{\"id\":266397645,\"identity\":\"923e0b5a-8605-4001-8974-ad3d01549d8e\",\"order_by\":1,\"name\":\"Chung Tin Ma\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Chung\",\"middleName\":\"Tin\",\"lastName\":\"Ma\",\"suffix\":\"\"},{\"id\":266397646,\"identity\":\"611c9d23-d711-4d11-ad44-2b81797b6e0a\",\"order_by\":2,\"name\":\"Michael Can Heng Li\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Michael\",\"middleName\":\"Can Heng\",\"lastName\":\"Li\",\"suffix\":\"\"},{\"id\":266397648,\"identity\":\"ede65217-4d07-4b6a-aff9-fcc98c28dc22\",\"order_by\":3,\"name\":\"Keary Rui Zhou\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Keary\",\"middleName\":\"Rui\",\"lastName\":\"Zhou\",\"suffix\":\"\"},{\"id\":266397649,\"identity\":\"1fce1841-01bc-4cc3-bbe5-6004e750fb58\",\"order_by\":4,\"name\":\"Herbert Ho Fung Loong\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Herbert\",\"middleName\":\"Ho Fung\",\"lastName\":\"Loong\",\"suffix\":\"\"},{\"id\":266397651,\"identity\":\"1080aff1-b79b-4ab5-868a-7315717dd00f\",\"order_by\":5,\"name\":\"Kwok Chuen Wong\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Prince of Wales Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Kwok\",\"middleName\":\"Chuen\",\"lastName\":\"Wong\",\"suffix\":\"\"},{\"id\":266397652,\"identity\":\"35f61676-76cb-4105-97d2-ab8a76201664\",\"order_by\":6,\"name\":\"Chi Kong Li\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Chi\",\"middleName\":\"Kong\",\"lastName\":\"Li\",\"suffix\":\"\"},{\"id\":266397653,\"identity\":\"c65e7109-3a86-4700-ab22-d923b2260242\",\"order_by\":7,\"name\":\"Yin Ting Cheung\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"The Chinese University of Hong Kong\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Yin\",\"middleName\":\"Ting\",\"lastName\":\"Cheung\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-01-09 07:59:13\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-3847610/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-3847610/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":49548057,\"identity\":\"7a4c51a4-586d-4e2b-bee9-ef91cc62e881\",\"added_by\":\"auto\",\"created_at\":\"2024-01-12 19:28:16\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":85420,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSurvivors’ Body Image Perception. The Body Image Scale consists of three domains, including the Cognitive, Affective and Behavioral subscales.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3847610/v1/2fcb3071fc6ea71a3b1efb0b.jpg\"},{\"id\":49547301,\"identity\":\"da9bfd0d-2f23-4e18-ac2b-61cc4763b4b2\",\"added_by\":\"auto\",\"created_at\":\"2024-01-12 19:20:16\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":142368,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eComparison of Behavioral Outcomes Between Survivors Who Were Satisfied (n=75) and Dissatisfied (n=41) with Their Body Image. A higher T score is indicative of worse functioning. * \\u003cem\\u003eP\\u003c/em\\u003e\\u0026lt;0.05.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"image2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3847610/v1/7c2d598ffb34ae12c21cf94b.jpg\"},{\"id\":54514619,\"identity\":\"e563ed8a-cbaf-4998-ac90-6922f58acbc3\",\"added_by\":\"auto\",\"created_at\":\"2024-04-11 16:20:05\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":574163,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3847610/v1/dd5a0b87-9bc4-4c2c-82ee-81fd9d0820ab.pdf\"},{\"id\":49547300,\"identity\":\"3d0296c8-1d5d-4ce9-9a82-5651a00d9da3\",\"added_by\":\"auto\",\"created_at\":\"2024-01-12 19:20:15\",\"extension\":\"docx\",\"order_by\":7,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":45520,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Supplinfo.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3847610/v1/19caaef9cb80692800072619.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Impact of Body Image Perception on Behavioral Outcomes in Chinese Adolescent and Young Adult Survivors of Sarcoma\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eOsteosarcoma and soft tissue sarcoma (STS) are relatively rare cancers among adolescents and young adults (AYAs). Improved treatment strategies for childhood osteosarcoma and STS that involve surgery, chemotherapy and radiation have led to increased survival rates [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. However, survivorship comes at the cost of developing myriad adverse effects that can affect the survivor\\u0026rsquo;s quality of life and functional outcomes later in life [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. The cancer experience and long-term side effects of treatment require major readjustments to survivors\\u0026rsquo; physical and role functioning, as well as to their social and interpersonal relationships.\\u003c/p\\u003e \\u003cp\\u003eDue to intensive surgical and radiological treatments, survivors of certain solid tumors may experience body image dissatisfaction and negative body changes such as scarring, amputation, and disfigurement, and these issues may persist into long-term survivorship [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Most studies on body image concerns have been conducted in adult patients with breast, head and neck, and gynecological cancers [\\u003cspan additionalcitationids=\\\"CR5 CR6\\\" citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Much less attention has been paid to body image concerns among survivors of sarcoma. Embarrassment and concerns about their altered physical appearance were common themes identified in a qualitative study on sarcoma survivors\\u0026rsquo; perspectives on their body image after resection/limb salvage surgery [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. One recent study also showed that patients with bone tumors reported worse scores than healthy controls for physical categories of quality of life, as well as for functional and aesthetic aspects of body image [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. This may reflect persistent body image concerns and negative perceptions of physical changes among survivors of sarcoma, especially those with scars or highly visible disfigurement.\\u003c/p\\u003e \\u003cp\\u003eAYAs with cancer may be particularly vulnerable to body image disturbance, as they are often affected by sociocultural factors such as peer pressure and media influence [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. When negative perceptions of body image are internalized, they may manifest as behavioral problems, such as social withdrawal, anxiety, and depression, during survivorship [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Among adult survivors of childhood cancer, it has been reported that body image dissatisfaction mediates the association between treatment-related scarring/disfigurement and psychological distress, regardless of sex [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. From a developmental perspective, the impact of scarring and/or disfigurement may be particularly detrimental when it is acquired in or persists through adolescence and young adulthood, because these periods are critical for establishing social and sexual identities.\\u003c/p\\u003e \\u003cp\\u003eCurrently, most reports of body image perception in AYA survivors of cancer relate to Western populations. Considering the significant role of culture in shaping appearance ideals, it is important to examine the impact of body image on behavioral problems in young Chinese survivors of sarcoma. The objectives of this study were (1) to identify clinical, treatment, and socioenvironmental factors associated with body image perception in Chinese AYA survivors of sarcoma, and (2) to evaluate the association between body image dissatisfaction and behavioral outcomes.\\u003c/p\\u003e\"},{\"header\":\"Material and methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy design\\u003c/h2\\u003e \\u003cp\\u003eThis cross-sectional study was conducted between June 2020 and May 2022 at the long-term survivors\\u0026rsquo; clinics of the Department of Orthopaedics and Traumatology and the Department of Paediatrics of the Prince of Wales Hospital in Hong Kong. Participants who were 18 years old or over were provided with written informed consent. For those who were under 18, written informed consent was provided by their parents. The study was approved by the Institution Review Board of the Joint Chinese University of Hong Kong\\u0026ndash;New Territories East Cluster Clinical Research Ethics Committee, Hong Kong, China (Ref: 2018.131). The study followed the Declaration of Helsinki ethical principles.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy population\\u003c/h2\\u003e \\u003cp\\u003eSurvivors were eligible for the study if they (1) were aged 15 to 39 years old, (2) had been diagnosed with osteosarcoma or STS, and (3) had survived for at least 5 years post-diagnosis and 2 years after completion of cancer treatment. Survivors who had any pre-existing developmental or behavioral disorders were excluded.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eBody image perception\\u003c/h2\\u003e \\u003cp\\u003eBody image perception was evaluated using the 10-item Body Image Scale (BIS)[\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e], which was developed to assess changes in body image in patients with cancer. The scale comprises (1) cognitive items, which relate to the cognitive appraisals individuals make of their appearance (e.g. dissatisfaction with one\\u0026rsquo;s appearance, or with scarring), (2) affective items, which relate to the emotions associated with one\\u0026rsquo;s appearance (e.g. feeling feminine, feeling attractive), and (3) behavioral items, which relate to how individuals behave toward their body (e.g. finding it hard to look at oneself naked, avoiding people because of one\\u0026rsquo;s appearance) [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Each item is assessed using a 4-point scale from \\u0026ldquo;not at all\\u0026rdquo; to \\u0026ldquo;very much\\u0026rdquo;. The BIS has been widely used as a tool to evaluate body image perception in diverse populations of cancer patients, and it has strong evidence supporting its structural validity, internal consistency, and reliability. The Chinese version of the BIS has been tested in Chinese patients with nasopharyngeal cancer [\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. A higher score is indicative of higher dissatisfaction with body image. Patients who reported a total score of \\u0026gt;\\u0026thinsp;10 points are categorized as \\u0026ldquo;dissatisfied with their body image\\u0026rdquo; [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR17\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eBehavioral outcomes\\u003c/h2\\u003e \\u003cp\\u003eBehavioral functioning was evaluated using the traditional Chinese version of the Achenbach System of Empirically Based Assessment (ASEBA) Adult Self-Report (ASR) checklist [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. The primary outcomes of interest were the DSM-oriented scales for Depressive Problems, Anxiety Problems, Somatic Problems, Avoidant Personality Problems, Attention Deficit/Hyperactivity (AD/H) Problems (Inattention and Hyperactivity/Impulsivity subscales), and Antisocial Personality Problems. The Chinese version of the ASR has been used and validated in the Chinese general population [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e].\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePredictors of body image perception\\u003c/h2\\u003e \\u003cp\\u003ePredictors of body image perception were determined \\u003cem\\u003ea priori\\u003c/em\\u003e based on a literature review. Sociodemographic predictors included sex, age at follow-up, highest educational attainment, and employment status [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. Clinical predictors were cancer diagnosis, age at cancer diagnosis, history of relapse, presence of chronic health conditions, and weight status [\\u003cspan additionalcitationids=\\\"CR23 CR24\\\" citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. Treatment predictors included surgery, radiation, and chemotherapy. Both the clinical information and the treatment information were abstracted from the Clinical Management System, an electronic health data repository of the public healthcare system in Hong Kong.\\u003c/p\\u003e \\u003cp\\u003eThe focal behavioral predictors were family functioning and physical activity. Family functioning was assessed using the validated Chinese Family Assessment Instrument (CFAI)[\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. The CFAI is a 33-item tool that measures the domains of mutuality, communication and cohesiveness, conflict and harmony, parental concern and parental control. The item scores are summed to yield total scores ranging from 33 to 165, and a higher score represents poorer family functioning. The participants self-reported their physical activity level using the validated Chinese University of Hong Kong: Physical Activity Rating for Children and Youth (CUHK-PARCY)[\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e], which uses an 11-point scale (0 to 10) to evaluate the level, intensity and frequency of physical activity based on the metabolic equivalent of task score. The CUHK-PARCY has been validated and has been used to measure physical activity in Chinese survivors of childhood cancer [\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e]. A score of 0\\u0026ndash;3 is regarded as indicating a low activity level, while 4\\u0026ndash;6 represents moderate activity and 7\\u0026ndash;10 indicates a high activity level.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e \\u003cp\\u003eThe sample characteristics and outcome measures were summarized using descriptive statistics for the overall cohort and stratified by body image perception. The Mann\\u0026ndash;Whitney U test or Kruskal\\u0026ndash;Wallis test (for continuous variables) and chi-square test (for categorial variables) were used to compare the sociodemographic, clinical, and behavioral characteristics of survivors who were satisfied versus dissatisfied with their body image. General linear modelling was conducted to evaluate the association between survivors\\u0026rsquo; characteristics and BIS scores.\\u003c/p\\u003e \\u003cp\\u003eFor behavioral outcomes, a one-sample \\u003cem\\u003et\\u003c/em\\u003e-test was used to compare the survivors\\u0026rsquo; performance with the normative data (\\u003cem\\u003et\\u003c/em\\u003e-score\\u0026thinsp;=\\u0026thinsp;50), correcting for false discovery rate [\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. General linear modeling was conducted to identify the factors associated with behavioral outcomes, adjusting for clinically relevant covariates that are associated with behavioral outcomes in survivors of cancer: age, sex, cancer diagnosis, surgery, radiation, and weight status [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]. Unstandardized point estimates (Est) and standard errors (SE) were used to quantify the effect size of the associations.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e\\n\\u003ch2\\u003eCharacteristics of study cohort\\u003c/h2\\u003e\\n\\u003cp\\u003eA total of 116 survivors were enrolled in the study (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The average age at evaluation was 28.2 (SD\\u0026thinsp;=\\u0026thinsp;8.2) years, and 48.3% were female. Approximately half of the survivors (50.9%) had been diagnosed with STS and 57 (49.1%) had been diagnosed with osteosarcoma. The average length of time since diagnosis was 14.9 (SD\\u0026thinsp;=\\u0026thinsp;7.6) years. A minority (10.3%) had experienced a relapse and almost half (46.9%) had developed chronic health conditions. Most of the survivors had received surgery (95.7%) or chemotherapy (91.9%). The majority of the osteosarcoma survivors had received tumor resection with prosthesis (35.7%) or allograph reconstruction (17.9%), while the majority of the STS survivors had received local tumor resection (43.7%). The mean BMI was 21.7 kg/m\\u003csup\\u003e2\\u003c/sup\\u003e (SD\\u0026thinsp;=\\u0026thinsp;3.9). Nearly a quarter (23.3%) of the survivors were overweight or obese, and 13.8% were underweight.\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eCharacteristics of Overall Participants and Grouped by Satisfaction of Body Image\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCharacteristics\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOverall\\u003c/p\\u003e\\n\\u003cp\\u003en\\u0026thinsp;=\\u0026thinsp;116\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDissatisfied\\u003c/p\\u003e\\n\\u003cp\\u003en\\u0026thinsp;=\\u0026thinsp;41\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSatisfied\\u003c/p\\u003e\\n\\u003cp\\u003en\\u0026thinsp;=\\u0026thinsp;75\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003en (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSex\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.93\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMale\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e60 (51.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e21 (51.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e39 (52.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFemale\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e56 (48.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (48.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e36 (48.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAge at Interview mean [SD]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e28.2 [8.2]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e31.0 [6.9]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e26.7 [8.5]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.001\\u003c/strong\\u003e\\u003csup\\u003e\\u003cstrong\\u003e#\\u003c/strong\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;15\\u0026ndash;18 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13 (11.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (2.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (16.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026ge;18\\u0026ndash;30 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e58 (50.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e15 (36.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e43 (57.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;30 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e45 (38.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e25 (61.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (26.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAge of cancer diagnosis mean [SD]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13.3 [7.2]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14.7 [5.7]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12.5 [7.9]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.032\\u003c/strong\\u003e\\u003csup\\u003e\\u003cstrong\\u003e#\\u003c/strong\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026lt; 15 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e76 (65.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e26 (63.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e50 (66.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026ge;15\\u0026ndash;20 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e27 (23.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e11 (26.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (21.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026ge;20\\u0026ndash;30 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e8 (6.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (6.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;30 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (4.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (2.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (5.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYears From Diagnosis mean [SD]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14.9 [7.6]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16.3 [7.1]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14.2 [7.8]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.076\\u003csup\\u003e#\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026le;5 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (13.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (14.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (13.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;5\\u0026ndash;10 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (13.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (4.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (18.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;10\\u0026ndash;20 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e53 (45.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e19 (46.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e34 (45.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u0026gt;20 years\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e31 (26.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (34.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e17 (22.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEducation Level\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.080\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSecondary school or below\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e42 (37.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (26.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e32 (43.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePost-secondary school or above\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e70 (62.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e28 (73.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e42 (56.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEmployment Status\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.025\\u003c/strong\\u003e\\u003csup\\u003e\\u003cstrong\\u003e*\\u003c/strong\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEmployed\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e81 (69.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e35 (85.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e46 (61.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNot employed\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (17.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e17 (22.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eStudents\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e15 (13.0))\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (16.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eClinical characteristics\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCancer\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.26\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSoft-tissue sarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e59 (50.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e18 (43.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e41 (54.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOsteosarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e57 (49.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e23 (56.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e34 (45.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSubtypes (for soft-tissue sarcoma only)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eN.A.\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eRhabdomyosarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (8.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (11.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEwing sarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e11 (18.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (22.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (17.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eLiposarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (3.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (5.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (2.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSynovial Sarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (8.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (11.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eClear Cell Sarcoma\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (6.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (9.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePNET\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (5.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e29 (49.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9 (50.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (48.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTumor site (for soft-tissue sarcoma)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eN.A.\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eLower extremity\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e18 (30.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (27.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e13 (31.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eUpper extremity\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (10.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (16.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAbdomen/pelvis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e17 (28.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e5 (27.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (29.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHead and neck\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (16.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (5.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9 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align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFemur\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e32 (56.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e15 (65.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e17 (50.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTibia\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (24.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (8.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 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align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (5.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (5.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (4.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (5.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eRelapse\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.26\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e104 (89.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e35 (85.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e69 (92.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (10.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (14.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (8.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCHCs\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.48\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e60 (53.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (48.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e40 (55.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e53 (46.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e21 (51.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e32 (44.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBody mass index mean [SD]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e21.7 [3.9]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e23.0 [4.9]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20.8 [2.8]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.032\\u003c/strong\\u003e\\u003csup\\u003e\\u003cstrong\\u003e#\\u003c/strong\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eUnderweight\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (13.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (17.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9 (12.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNormal\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e73 (62.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e19 (46.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e54 (72.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOverweight/obese\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e27 (23.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e15 (36.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (16.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTreatment characteristics\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eChemotherapy\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.47\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e21 (18.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e6 (14.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e15 (20.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e95 (91.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e35 (85.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e60 (80.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eRadiation\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.69\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e78 (68.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e29 (70.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e49 (67.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e36 (31.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (29.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e24 (32.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSurgery\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.13\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eNo\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (3.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (5.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e112 (96.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e41 (100)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e71 (94.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.077\\u003csup\\u003e*^\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAmputation\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (2.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3 (7.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eResection with allograph\\u003c/p\\u003e\\n\\u003cp\\u003ereconstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (17.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e8 (19.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (16.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eResection with prosthesis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e40 (35.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e16 (39.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e24 (33.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eResection (other sites)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e49 (43.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (34.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e35 (49.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eLobectomy due to metastatic\\u003c/p\\u003e\\n\\u003cp\\u003etumor\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e11 (9.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e7 (17.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (5.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eTreatment combinations\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.44\\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSurgery only\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e14 (12.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (9.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (13.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSurgery and chemotherapy\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e63 (54.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e25 (61.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e38 (50.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSurgery, chemotherapy and radiation\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e27 (23.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (24.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e17 (22.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOthers\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e12 (10.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (4.9)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e10 (13.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBehavior characteristics\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eFamily functioning mean [SD]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e89.1 [14.8]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e92.7 [13.1]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e87.0 [15.3]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.034\\u003c/strong\\u003e\\u003csup\\u003e\\u003cstrong\\u003e#\\u003c/strong\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003ePhysical activity mean [SD]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4.3 [2.8]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4.1 [2.9]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4.5 [2.8]\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.50\\u003csup\\u003e#\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eLow level (0 to 3 points)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e50 (43.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e21 (51.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e29 (38.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eModerate level (4 to 6 points)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e40 (34.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e11 (26.8)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e29 (38.7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eHigh level (7 to 10 points)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e26 (22.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e8 (22.0)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e17 (22.6)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eCHC: chronic health condition; N.A.: Not applicable (comparison was not conducted due to the small sample size); PNET: primitive neuro-ectodermal tumor\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e*\\u003c/sup\\u003eComparison was conducted using Chi-square test between dissatisfied group and satisfied group.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e#\\u003c/sup\\u003eComparison was conducted using Mann-Whitney U test between dissatisfied group and satisfied group.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e^\\u003c/sup\\u003eComparison was conducted among individuals who received amputation versus resection with allograph versus resection with prosthesis.\\u003c/p\\u003e\\n\\u003cp\\u003eBoldface indicates statistical significance at \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05.\\u003c/p\\u003e\\n\\u003cp\\u003eMost of the participants had a level of education higher than secondary school (62.5%) and were employed at the time of the interview (69.8%). The mean CUHK-PARCY score for physical activity was 4.3 (SD\\u0026thinsp;=\\u0026thinsp;2.8), indicating a moderate level of physical activity. The mean family functioning score was 89.1 (SD\\u0026thinsp;=\\u0026thinsp;14.8).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e\\n\\u003ch2\\u003eBody image perception\\u003c/h2\\u003e\\n\\u003cp\\u003eThe median BIS score was 8 (range\\u0026thinsp;=\\u0026thinsp;4\\u0026ndash;14) and the mean score was 9.4 (SD\\u0026thinsp;=\\u0026thinsp;7.1) (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Based on the published cutoffs, the prevalence of body image dissatisfaction was 35.3%. The largest proportion of dissatisfaction was observed on the cognitive subscale (48.3%), followed by the affective subscale (29.3%) and the behavioral subscale (17.2%).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eBody image scale total score and subscale scores\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n\\u003cth colspan=\\\"2\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eOverall\\u003c/p\\u003e\\n\\u003cp\\u003en\\u0026thinsp;=\\u0026thinsp;116\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDissatisfied with body image \\u003csup\\u003e*\\u003c/sup\\u003e\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMean (SD)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eMedian (IQR)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003en (%)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBody image scale (total score)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e9.4 (7.1)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e8 (4\\u0026ndash;14)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e41 (35.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAffective subscale score\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e3.3 (3.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e2 (1\\u0026ndash;5.5)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e34 (29.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBehavioral subscale score\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1.2 (1.4)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e1 (0\\u0026ndash;2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e20 (17.2)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCognitive subscale score\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4.9 (3.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e4 (3\\u0026ndash;7)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e56 (48.3)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eSD: standard deviation; IQR: interquartile range\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e*\\u003c/sup\\u003e Patients who reported a total score of \\u0026gt;\\u0026thinsp;10 points are categorized as \\u0026ldquo;dissatisfied with their body image\\u0026rdquo;.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Affective and cognitive subscale each includes 4 items, with scores ranging from 0 to 12. \\u0026ldquo;Dissatisfaction\\u0026rdquo; was defined as a subscale score\\u0026thinsp;\\u0026gt;\\u0026thinsp;4 points.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Behavioral subscale includes 2 items, with score ranging from 0 to 6. \\u0026ldquo;Dissatisfaction\\u0026rdquo; was defined as a subscale score\\u0026thinsp;\\u0026gt;\\u0026thinsp;2 points.\\u003c/p\\u003e\\n\\u003cp\\u003eDetails of the participants\\u0026rsquo; body image perception are presented in Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. Approximately one third of the survivors reported dissatisfaction with their appearance. Among the affective items, survivors reported most concern about being \\u0026ldquo;less physically attractive\\u0026rdquo; (34.5%) and \\u0026ldquo;less wholesome\\u0026rdquo; (31%); 40.5% reported that they felt \\u0026ldquo;self-conscious\\u0026rdquo; about their appearance. Only 8.7% of the survivors were quite or very concerned about seeing themselves naked.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e\\n\\u003ch2\\u003eComparison of characteristics of participants with versus without body image dissatisfaction\\u003c/h2\\u003e\\n\\u003cp\\u003eThe demographic, clinical, treatment, and behavioral characteristics of survivors who were satisfied and dissatisfied with their body image are compared in Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. Compared with survivors who were satisfied with their body image, survivors who were dissatisfied were older both at interview (mean\\u0026thinsp;=\\u0026thinsp;31.0 years, SD\\u0026thinsp;=\\u0026thinsp;6.9 years versus mean\\u0026thinsp;=\\u0026thinsp;26.7 years, SD\\u0026thinsp;=\\u0026thinsp;8.5 years, respectively; P\\u0026thinsp;=\\u0026thinsp;0.001) and at cancer diagnosis (mean\\u0026thinsp;=\\u0026thinsp;14.7 years, SD\\u0026thinsp;=\\u0026thinsp;5.7 years versus mean\\u0026thinsp;=\\u0026thinsp;12.5 years, SD\\u0026thinsp;=\\u0026thinsp;7.9 years, respectively; P\\u0026thinsp;=\\u0026thinsp;0.032). The proportion of the dissatisfied group in full-time employment was larger than that of the satisfied group (85.4% versus 61.3%; P\\u0026thinsp;=\\u0026thinsp;0.025). Survivors with body image dissatisfaction also had a higher BMI than those who reported satisfaction (mean\\u0026thinsp;=\\u0026thinsp;23.0, SD\\u0026thinsp;=\\u0026thinsp;4.9 kg/m\\u003csup\\u003e2\\u003c/sup\\u003e versus mean\\u0026thinsp;=\\u0026thinsp;20.8, SD\\u0026thinsp;=\\u0026thinsp;2.8 kg/m\\u003csup\\u003e2\\u003c/sup\\u003e; P\\u0026thinsp;=\\u0026thinsp;0.032). Survivors with body image dissatisfaction reported higher total CFAI scores (mean\\u0026thinsp;=\\u0026thinsp;92.7, SD\\u0026thinsp;=\\u0026thinsp;13.1 versus mean\\u0026thinsp;=\\u0026thinsp;87.0, SD\\u0026thinsp;=\\u0026thinsp;15.3; P\\u0026thinsp;=\\u0026thinsp;0.044), indicating relatively poor family functioning in the dissatisfied group. The two groups did not significantly differ in terms of educational attainment, subtype of sarcoma, or level of physical activity.\\u003c/p\\u003e\\n\\u003cp\\u003eThe multivariable analyses showed that the significant risk factors predicting a poorer score on the BIS were being female (Est\\u0026thinsp;=\\u0026thinsp;3.015, SE\\u0026thinsp;=\\u0026thinsp;1.496; P\\u0026thinsp;=\\u0026thinsp;0.047), surgery treatment (Est\\u0026thinsp;=\\u0026thinsp;7.414, SE\\u0026thinsp;=\\u0026thinsp;3.659; P\\u0026thinsp;=\\u0026thinsp;0.046) and worse family functioning (Est\\u0026thinsp;=\\u0026thinsp;0.131, SE\\u0026thinsp;=\\u0026thinsp;0.051, P\\u0026thinsp;=\\u0026thinsp;0.013) (Supplemental Table\\u0026nbsp;1). There was a significant difference in BIS total score when comparing four groups of survivors with different surgery sites (P\\u0026thinsp;=\\u0026thinsp;0.042). The three survivors who had undergone amputation reported poorer body image perception (BIS mean score\\u0026thinsp;=\\u0026thinsp;19.3, SD\\u0026thinsp;=\\u0026thinsp;4.0) than those who had received other types of surgeries (Supplemental Table\\u0026nbsp;2).\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e\\n\\u003ch2\\u003eBehavioral outcomes in the overall cohort\\u003c/h2\\u003e\\n\\u003cp\\u003eCompared with the reference norm (mean\\u0026thinsp;=\\u0026thinsp;50, SD\\u0026thinsp;=\\u0026thinsp;10), the participants in our study demonstrated poorer outcomes in all measured behavioral domains (Fig.\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). A minority reported impairment from depressive problems (13.8%), anxiety (4.3%), somatic problems (6.0%), avoidant personality problems (6.9%), AD/H problems (6.0%) and antisocial problems (6.0%). The mean scores and impairment rates for behavioral measures in the study cohort, and in participants who reported dissatisfaction or satisfaction with their body image perception, are shown in Supplemental Table\\u0026nbsp;3.\\u003c/p\\u003e\\n\\u003cp\\u003eCompared with survivors who were satisfied with their body image, survivors in the dissatisfaction group reported significantly more depressive problems (P\\u0026thinsp;=\\u0026thinsp;0.004), anxiety problems (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), somatic problems (P\\u0026thinsp;=\\u0026thinsp;0.014), avoidant personality problems (P\\u0026thinsp;=\\u0026thinsp;0.002) and AD/H problems (P\\u0026thinsp;=\\u0026thinsp;0.037). No differences were found between the groups for the other behavioral outcome scores.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e\\n\\u003ch2\\u003eAssociation between body image perception and behavioral outcomes\\u003c/h2\\u003e\\n\\u003cp\\u003eAfter adjusting for age at interview, sex, type of cancer diagnosis, treatment modalities and weight status, the multivariate analyses showed that higher BIS total scores were associated with more depressive problems (Est\\u0026thinsp;=\\u0026thinsp;0.29, SE\\u0026thinsp;=\\u0026thinsp;0.10; P\\u0026thinsp;=\\u0026thinsp;0.005), anxiety problems (Est\\u0026thinsp;=\\u0026thinsp;0.38, SE\\u0026thinsp;=\\u0026thinsp;0.12; P\\u0026thinsp;=\\u0026thinsp;0.002) and avoidant personality problems (Est\\u0026thinsp;=\\u0026thinsp;0.41, SE\\u0026thinsp;=\\u0026thinsp;0.12; P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) (Table\\u0026nbsp;\\u003cspan class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cdiv class=\\\"gridtable\\\"\\u003e\\n\\u003ctable id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\n\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n\\u003cp\\u003eAssociation between Body Image Satisfaction and Behavioral Outcomes\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003c/caption\\u003e\\n\\u003cthead\\u003e\\n\\u003ctr\\u003e\\n\\u003cth align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\n\\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eDepressive problems*\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAnxiety problems*\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSomatic problems*\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAvoidant personality problems*\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAttention Deficit/ Hyperactivity Problems*\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003cth colspan=\\\"3\\\" align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAntisocial personality*\\u003c/p\\u003e\\n\\u003c/th\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/thead\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEst\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSE\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEst\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSE\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEst\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSE\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEst\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSE\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEst\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSE\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eEst\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eSE\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBody image scale (total score)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.29\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.10\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.005\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.38\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.12\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.002\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.22\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.12\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.066\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.41\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.12\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.19\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.12\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.113\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.17\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.13\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.206\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eAffective subscale score\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.11\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.015\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.18\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.002\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.08\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.122\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.17\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.002\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.06\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.275\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.06\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.402\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eBehavioral subscale score\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.61\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.02\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.003\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.03\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.050\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.02\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.053\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.08\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.02\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.02\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.037\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.03\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.039\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003eCognitive subscale score\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.11\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.04\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.013\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.16\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.005\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.09\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.087\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.15\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e0.005\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.08\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.05\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.125\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.06\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.06\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd align=\\\"left\\\"\\u003e\\n\\u003cp\\u003e0.281\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eEst: estimate; SE: standard error\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cp\\u003e\\u003csup\\u003e*\\u003c/sup\\u003eA higher score was indicative of worse functioning. All models were adjusted for age, sex, cancer diagnosis, surgery, radiation, and weight status. Boldface indicates statistical significance at \\u003cem\\u003eP\\u003c/em\\u003e\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05.\\u003c/p\\u003e\\n\\u003cp\\u003eThe subscales analyses showed that poorer body image perception in the behavioral domain was significantly associated with more depressive problems (Est\\u0026thinsp;=\\u0026thinsp;0.61, SD\\u0026thinsp;=\\u0026thinsp;0.02; P\\u0026thinsp;=\\u0026thinsp;0.003), avoidant personality problems (Est\\u0026thinsp;=\\u0026thinsp;0.08, SE\\u0026thinsp;=\\u0026thinsp;0.02; P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), AD/H problems (Est\\u0026thinsp;=\\u0026thinsp;0.05, SE\\u0026thinsp;=\\u0026thinsp;0.02; P\\u0026thinsp;=\\u0026thinsp;0.037), and antisocial personality problems (Est\\u0026thinsp;=\\u0026thinsp;0.05, SE\\u0026thinsp;=\\u0026thinsp;0.03; P\\u0026thinsp;=\\u0026thinsp;0.039).\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis is the first study investigating body image dissatisfaction and its associated factors among Chinese survivors of sarcoma. Over one third of the Chinese AYA survivors of sarcoma in the study reported dissatisfaction with their body image. Female (vs. male) participants and those who had (vs. those who had not) undergone surgery were more likely to have concerns about their appearance. Higher rates of behavioral problems were found among the participants compared with population norms. Importantly, poor body image perception was associated with more significant internalizing symptoms of depression, anxiety, and avoidant personality. Our findings highlight the challenges of body image perception for Chinese AYAs with cancer, and suggest that advocacy efforts aimed at improving the body image of young people in Hong Kong are critically needed. Body image can be considered a potential modifiable risk factor to address psychological symptoms in the Chinese population, which could inform future psychological interventions focused on improving body image perception among AYA survivors with sarcoma.\\u003c/p\\u003e \\u003cp\\u003eBody image changes are a major psychosocial concern and a key determinant of decreased quality of life among cancer survivors [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e], which can lead to difficulties with self-awareness and peer pressure [\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e], especially among AYAs [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e]. The participants in our study who had undergone surgery reported worse body image perceptions, which is consistent with earlier research. For example, one qualitative study reported that sarcoma survivors described altered appearances and impaired self-esteem after surgical treatment, which made them feel unattractive and more sensitive to staring and reactions from other people [\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e]. Body image concerns may be more relevant to survivors of sarcoma compared with other types of cancer because they typically receive extensive resection of tumor sites in parts of the body that are visible. We found that survivors who had undergone amputation reported poorer body image perception than those who had received other types of surgeries. Fortunately, most patients with osteosarcoma or STS in upper or lower extremities can now be treated with limb-salvage surgery, which has less impact on patients\\u0026rsquo; daily activities compared with limb amputation [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e]. However, the use of a prosthesis may still affect limb functioning, resulting in limited movement and disfiguration. Importantly, we did not find significant differences in body image perception among osteosarcoma survivors who had received tumor resection with allograft reconstruction versus prosthesis, and studies have shown that the former approach is associated with substantially improved functional outcomes [\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e]. Our findings reinforce the need for holistic care for survivors of sarcoma; in addition to examining the health status and functional limitations of sarcoma survivors, long-term follow-up consultations should include questions about body image and mobility to better identify survivors who need psychological assistance.\\u003c/p\\u003e \\u003cp\\u003eAs previously noted, we found that one third of the survivors (35.3%) were not satisfied with their body image. In the literature, the proportion of body image dissatisfaction ranges from 13\\u0026ndash;28% among patients with head and neck cancer, breast cancer, and brain tumors in North America and Europe [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e]. However, relatively few studies have been conducted in Asian populations. One Korean study reported that 39.3% of survivors of hematological malignancies reported body image dissatisfaction [\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e]. Cultural differences play an important role in disparities in body image perception, as perceptions of body shape and beauty are often influenced by social expectations and societal norms. A cross-cultural study found more body image concerns among both female and male adolescents from Malaysia and China than those from Australia, particularly regarding weight, body shape, hair, and extremities [\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e]. Studies have shown that Asians are more likely to feel distressed by and anxious about deviating body features, even when the differences are hardly noticeable. For example, normal weight and underweight Asian women had a tendency to view themselves as overweight [\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e]. Consistent with the literature [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e], our study found that females were more likely to be self-conscious about their altered appearance. Our univariate analysis also found a larger proportion of overweight/obese individuals in the dissatisfied group than the satisfied group, possibly because survivors of osteosarcoma may have problems engaging in strenuous exercise. Applying the study findings to the local context, partnership with non-governmental organizations (NGOs) may help survivors reconstruct their confidence and acquire social skills during cancer survivorship. As osteosarcoma survivors with amputation or prosthesis or previous lobectomy due to tumor metastasis might not be able to engage in strenuous activities, light physical activities like yoga, Qigong and Taiji under professional guidance can both enhance vitality and strengthen overall health in this cohort [\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e]. Considering the multiple positive outcomes associated with physical activity, encouraging survivors to engage in existing exercise programs offered by local NGOs and academic institutions may also improve survivors\\u0026rsquo; self-esteem and body image.\\u003c/p\\u003e \\u003cp\\u003eConsistent with the literature, we found significantly higher rates of behavioral problems in the overall cohort of sarcoma survivors compared with population norms. Participants with body image dissatisfaction demonstrated worse depression, anxiety, and avoidant personality problems than those who did not express concerns about their body image. This finding reveals the detrimental impact of negative body image perceptions on survivors\\u0026rsquo; internalizing behaviors. AYA patients may experience negative emotional reactions due to unexpected cancer-related body changes [\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e]. Body image dissatisfaction on the cognitive subscale was strongly associated with internalizing behavioral symptoms, suggesting that many patients have a distorted perception of their appearance that manifests as avoidance and social anxiety even years after completion of cancer treatment. The intrinsic thoughts and beliefs that patients hold about their body and their subjective feelings about their appearance may mediate the relationship between the cancer experience and emotional distress. However, changes in appearance may not always lead to negative sequelae [\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e]; a change can contribute to mental resilience when appraised in a positive light. For example, acceptance of changes in appearance and engagement in self-care are associated with resilience and positive illness perception in Asian women with breast cancer [\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. Such positive changes are in line with theoretical conceptualizations of posttraumatic growth in response to negative life events [\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e]. Future work should explore the mediating role of body image in illness perception and resilience, and implement interventions early, before distress develops into significant psychological problems that affect patients\\u0026rsquo; functional outcomes.\\u003c/p\\u003e \\u003cp\\u003eWe also found that dissatisfaction on the behavioral subscale was associated with avoidant personality problems and antisocial personality, suggesting worse interpersonal functioning. Body image concerns may affect survivors\\u0026rsquo; social and intimate relationships, resulting in avoidance and alienation from peers [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e]. Our study also showed that poor family functioning was associated with negative body image perception. Interestingly, one study reported that among the different sources of social support (family, friends, and significant others), only support from friends significantly mediated the association between body image distress and depressive symptoms in patients with cancer [\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e]. Peer support groups allow survivors to openly share, discuss, and encourage each other for resilience and self-acceptance, which can further help reduce appearance-related anxiety [\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e]. Collectively, these findings support leveraging survivors\\u0026rsquo; existing social network to improve their perception of body image and their interpersonal relationships. For example, adolescent survivors of osteosarcoma often need special assistance when they return to school after treatment [\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e]; peer support and buddy programs may help to provide a supportive social environment and improve mental health outcomes as patients transition into survivorship.\\u003c/p\\u003e \\u003cp\\u003eOur study has several limitations. First, causal and temporal relationships between body image perception and behavioral symptoms cannot be established, due to the cross-sectional design of the study. It is likely that body image perception and behavioral symptoms co-exist and can interact with each other. The mechanism of associations between body image dissatisfaction and behavioral outcomes requires prospective investigation throughout the cancer care continuum from diagnosis to long-term survivorship. Second, our results are limited by the absence of a non-cancer control group. However, the impact of cancer on body image perception has been extensively reported in the literature [\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e]. Therefore, the risk factor analysis and the associations between body image and behavioral outcomes might still be valid and applicable to the population of AYA cancer survivors. Third, our study population was small and participants were recruited from a single public hospital. However, survivors of osteosarcoma and STS who are treated in the public healthcare system in Hong Kong typically receive standard treatment protocols that are similar to other developed countries. Hence, it is reasonable to assume that our findings might be generalizable to other AYA survivors of sarcoma in Hong Kong, and can also provide a foundation for further studies in other Asian countries or regions.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eOur study provides important perspectives on the evidence of body image distress in long-term survivors of sarcoma. Negative perception of body image was associated with depression, anxiety and avoidant personality problems. Disparities in body image dissatisfaction between Asian and Western populations offer insight into cultural differences. Future research should focus on identifying survivors who are at risk of experiencing negative body image perception and implementing psychological interventions specifically focused on addressing body image dissatisfaction in AYA survivors of sarcoma. The provision of social support and psychosocial intervention early during the cancer care continuum may mitigate the negative impact of body image distress in AYA survivors.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003eFundings\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study is funded by the Hong Kong Research Grant Council, General Research Fund (Ref: 14601919).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eCompeting Interests\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no relevant financial or non-financial interests to disclose.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eAuthor Contributions\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by YT, CT, HF, KC, CK. Data analysis was performed by YH and YT. The first draft of the manuscript was written by YH and YT and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eEthics approval\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis is an observational study. The study was approved by the Institution Review Board of the Joint Chinese University of Hong Kong\\u0026ndash;New Territories East Cluster Clinical Research Ethics Committee, Hong Kong, China (Ref: 2018.131). The study followed the Declaration of Helsinki ethical principles.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eConsent to participate\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eInformed consent was obtained from all individual participants included in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eConsent to publish\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors affirm that human research participants provided informed consent for publication of the Tables 1, 2 and 3, and images in Figures 1 and 2.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eJanssen, S.H.M., et al., \\u003cem\\u003eAdolescent and Young Adult (AYA) Cancer Survivorship Practices: An Overview.\\u003c/em\\u003e Cancers (Basel), 2021. \\u003cstrong\\u003e13\\u003c/strong\\u003e(19).\\u003c/li\\u003e\\n\\u003cli\\u003eClose, A.G., et al., \\u003cem\\u003eAdolescent and young adult oncology-past, present, and future.\\u003c/em\\u003e CA Cancer J Clin, 2019. \\u003cstrong\\u003e69\\u003c/strong\\u003e(6): p. 485-496.\\u003c/li\\u003e\\n\\u003cli\\u003eFingeret, M.C., I. 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Hagedoorn, and M.A. Tuinman, \\u003cem\\u003eBody image in cancer survivors: a systematic review of case-control studies.\\u003c/em\\u003e J Cancer Surviv, 2015. \\u003cstrong\\u003e9\\u003c/strong\\u003e(2): p. 339-48.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Adolescents and young adults, sarcoma survivors, body image dissatisfaction, behavioral outcomes\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-3847610/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-3847610/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eTo identify the prevalence and predictive factors of body image dissatisfaction among Chinese adolescent and young adult (AYA) survivors of sarcoma, and to evaluate its associations with behavioral outcomes.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eIn total, 116 AYA survivors (48.3% female; mean age 28.2 years, SD\\u0026thinsp;=\\u0026thinsp;8.2 years) of osteosarcoma (49.1%) or soft-tissue sarcoma (50.9%) were recruited from an academic hospital. The survivors self-reported their perceived body image using the Body Image Scale. Behavioral outcomes were assessed using DSM-oriented scales of the ASEBA Adult Self-Report checklist. Multivariable linear regression was conducted to identify predictors of body image perception and investigate the association between body image dissatisfaction and behavioral outcomes.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eAt 15 years post-cancer diagnosis, one third of the cohort (35.3%) reported dissatisfaction with their body image. Female survivors (Est\\u0026thinsp;=\\u0026thinsp;3.13, SE\\u0026thinsp;=\\u0026thinsp;1.53; P\\u0026thinsp;=\\u0026thinsp;0.044) and survivors who had undergone surgery (Est\\u0026thinsp;=\\u0026thinsp;7.13, SE\\u0026thinsp;=\\u0026thinsp;3.35; P\\u0026thinsp;=\\u0026thinsp;0.037) reported poorer body image perception. Body image dissatisfaction was associated with symptoms of depression (Est\\u0026thinsp;=\\u0026thinsp;0.29, SE\\u0026thinsp;=\\u0026thinsp;0.10; P\\u0026thinsp;=\\u0026thinsp;0.005) and avoidant personality (Est\\u0026thinsp;=\\u0026thinsp;0.41, SE\\u0026thinsp;=\\u0026thinsp;0.12; P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eA negative perception of body image was associated with psychological distress in long-term survivorship. The provision of psychosocial intervention early during the cancer care continuum may mitigate the negative impact of body image distress in AYA survivors.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Impact of Body Image Perception on Behavioral Outcomes in Chinese Adolescent and Young Adult Survivors of Sarcoma\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-01-12 19:20:11\",\"doi\":\"10.21203/rs.3.rs-3847610/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"2bd0b8fa-91a4-48ca-860d-a6307cc3055c\",\"owner\":[],\"postedDate\":\"January 12th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2024-04-11T16:11:57+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-01-12 19:20:11\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-3847610\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-3847610\",\"identity\":\"rs-3847610\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}