Cancer is one of the most significant health challenges today, being the second most common cause of death worldwide, following only heart-related conditions.¹ Cancer is characterized by uncontrolled cellular proliferation, resulting in the formation of a mass of cancerous cells, or a tumor.

This uncontrolled growth is marked by cellular transformation and a loss of cellular differentiation. Approximately 1 in 5 men or women develops cancer in their lifetime.² Among the diverse cancer types, breast cancer is the most prevalent cancer in women, representing 25% of all female cancers, and is considered the deadliest malignancy affecting women³, posing a significant global health concern.⁴

A breast cancer diagnosis profoundly impacts all facets of a woman’s life, particularly sexual function and marital quality of life.⁵ Treatments like mastectomy can alter body image and reduce sexual desire, while chemotherapy induces fatigue, hormonal changes, and vaginal dryness, impairing intimacy and straining marital bonds.⁶ The family, a dynamic institution shaped by continuous, interactive communication, evolves over time and space, with these effects reverberating across spouses, children, and society⁷, highlighting the need for targeted support.

Empirical evidence demonstrates the association between marital quality of life and a multitude of factors, some of which are addressed in this study. Marital expectations appear to be one such factor.⁸ Expectations are categorized as 1 of 5 key cognitive phenomena (expectations, perceptions, attributions, standards, and assumptions) that, when inaccurate or excessive, can contribute to marital discord.⁹ Marital expectations refer to the mental standards, hypotheses, pre-established frameworks, and perceived obligations and prohibitions couples hold about their spouse and relationship, which may or may not align with reality.¹⁰

Furthermore, body image in women with breast cancer can significantly influence their marital quality of life.¹¹ Body image transcends personal identity, serving as a crucial component of social identity, particularly within the context of intimate relationships. Our perception of our bodies (i.e., how we see ourselves) can affect our ability to engage in social interactions and subsequently shape how others perceive and interact with us.¹² Specifically, within a marital context, changes in body image resulting from breast cancer treatment can impact a woman’s sense of attractiveness and femininity, influencing her confidence and intimacy with her partner. This aligns with social identity theory, which posits that individuals derive a sense of self from their perceived membership in social groups and that positive social identity is linked to psychological well-being.¹³ Consistent with this, Noori and Johari Fard¹⁴ demonstrated a relationship between body image and appearance with quality of life, while also finding an inverse relationship between obsessive beliefs and quality of life. Similarly, Rasekh Jahromi et al.¹⁵ found a significant association between sexual function and body image in women with breast cancer, further supporting the link between body image and relational well-being.

Sexual satisfaction, defined as the degree of contentment from sexual interactions and mutual pleasure¹⁶, significantly influences the marital quality of life. Its absence compromises relationship stability, reducing resilience against life’s challenges and interpersonal difficulties.¹⁷ Breast cancer-related challenges can diminish marital bonds, potentially leading to divorce, a critical family communication breakdown.^18,19

The diagnosis and treatment of breast cancer present multifaceted challenges to women, extending far beyond physical health to deeply affect their psychological and emotional well-being, as well as their relational dynamics. Specifically, the experience can profoundly disrupt body image, sexual satisfaction, and marital relationships, often leading to heightened emotional distress, anxiety, and a diminished sense of self-worth. The psychological toll of altered body image, stemming from surgery, hair loss, or other treatment-related changes, can foster feelings of shame, insecurity, or loss of femininity, which may, in turn, erode sexual satisfaction and intimacy. These interconnected factors can contribute to a significant decline in marital quality of life, which is a critical component of overall well-being, as emotional disconnection or unmet relational expectations exacerbate the strain.

While previous research has explored the individual impacts of body image, sexual satisfaction, and marital expectations on marital quality of life in women with breast cancer, a significant research gap exists in understanding the complex interrelationships between these factors, particularly the mediating role of sexual satisfaction in specific cultural contexts like Ahvaz. Prior studies have not comprehensively examined how body image and marital expectations indirectly affect marital quality of life through their impact on sexual satisfaction in this region, where cultural and religious norms may uniquely shape these dynamics. The present study addresses this gap by providing a novel mediation analysis that elucidates the specific pathways through which these factors interact in Ahvaz. Investigating these pathways, with sexual satisfaction as a potential mediating factor, is essential for developing targeted interventions that address both the emotional and relational dimensions of this experience in this cultural context. Therefore, this research aims to examine the relationship between marital expectations and body image with marital quality of life in women with breast cancer in Ahvaz, specifically exploring the mediating role of sexual satisfaction in this complex emotional and psychological landscape.

This research utilized a cross-sectional, descriptive, and correlational approach, incorporating path analysis to explore possible associations among the studied variables. The explanatory variables included marital expectations and body image as predictors, with sexual satisfaction serving as a mediator. The outcome of interest was marital quality of life, which was assessed to understand how these predictors and the mediator affect it in women with breast cancer. The study population included all women diagnosed with breast cancer receiving care at specialized oncology clinics in Ahvaz, Iran, in 2024. Using a convenience sampling approach, 180 eligible participants were enrolled, with the sample size calculated to account for the study variables and ensure sufficient statistical power. Among those invited, 161 women (89.4%) agreed to participate and completed the questionnaires. Inclusion criteria were a confirmed breast cancer diagnosis, female gender, age between 25 and 65 years, ability to read and write in Persian, and provision of informed consent. Exclusion criteria included the presence of other severe chronic medical conditions (e.g., metastatic cancer, heart failure, advanced diabetes, or chronic kidney disease), a history of mental disorders or cognitive impairment that could affect informed consent or accurate questionnaire completion, participation in other similar research projects, and incomplete questionnaire completion. All participants provided written informed consent after receiving a full explanation of the study’s purpose, procedures, potential risks, and benefits. Participants were assured of the confidentiality of their responses, as data were anonymized to protect their privacy. Participation was voluntary with the option to withdraw at any time without penalty. The participants were provided with contact information of the research team and relevant support services.

The present study comprised 161 women diagnosed with breast cancer, with ages spanning from 25 to 65 years (45.3 ± 9.8). The sample exhibited heterogeneity in educational attainment: 28% had completed high school or less, 42% held a college or an associate degree, and 30% had a bachelor’s degree or higher. Disease duration ranged from 6 months to 10 years post-diagnosis, with a mean duration of 3.2 years (SD, 2.1). Furthermore, 68% of the participants were married for 2 to 40 years (18.5 ± 10.3). The remaining 32% of the sample were identified as single, divorced, or widowed at the time of data collection.

Table 1 presents descriptive statistics and Pearson correlation coefficients for the study variables: marital quality of life, marital expectations, body image, and sexual satisfaction. Mean scores suggest moderate levels of marital quality of life (42.95 ± 8.89) and sexual satisfaction (56.55 ± 11.60), with relatively higher scores for marital expectations (77.26 ± 19.07) and body image (79.74 ± 21.35). Correlation analyses revealed significant positive relationships between the variables. Marital quality of life positively correlated with sexual satisfaction (r = 0.45, P<0.01), marital expectations (r = 0.21, P<0.05), and body image (r = 0.30, P<0.01). Marital expectations and body image were positively correlated (r = 0.36, P<0.01). Both marital expectations (r = 0.52, P<0.01) and body image (r = 0.60, P<0.01) positively correlated with sexual satisfaction. The initial proposed model is presented in Figure 1.

The initial model yielded the following indices: TLI=0.89, CFI=0.90, RFI=0.90, NFI=0.90, and RMSEA=0.37, indicating a suboptimal fit to the observed data. Between the proposed and final models, the direct path from marital expectations to marital quality of life was removed to improve fit. Conversely, the final model demonstrated superior fit, evidenced by TLI=0.99, CFI=0.99, RFI=0.99, NFI=0.99, and RMSEA=0.01. These metrics signify a substantial enhancement in model fit for the revised model, affirming its greater congruence with the data and its enhanced ability to represent the interrelationships among the variables.

Table 2 presents the standardized path coefficients (β) and associated significance levels (P) for the direct and indirect effects among the research variables in the final model, offering insight into the strength and direction of these relationships. The results reveal that marital expectations exerted a significant positive direct effect on sexual satisfaction (β=0.32, P<0.001), indicating that higher marital expectations were associated with a substantial increase in sexual satisfaction, specifically, a 0.32 SD increase for each SD increase in expectations. Similarly, body image had a significant positive direct effect on both marital quality of life (β=0.22, P<0.001) and sexual satisfaction (β=0.25, P<0.001), suggesting that better body image was linked to increases of 0.22 and 0.25 SDs in marital quality of life and sexual satisfaction, respectively, per 1 SD improvement in body image. In contrast, sexual satisfaction demonstrated a significant positive direct effect on marital quality of life (β=0.39, P<0.001), implying that a 1-SD increase in sexual satisfaction corresponded to a 0.39-SD improvement in marital quality of life.

Beyond direct effects, the analysis also uncovered significant indirect effects, which highlight the mediating role of sexual satisfaction. Marital expectations showed a significant positive indirect effect on marital quality of life through sexual satisfaction (β=0.19, P<0.001), meaning that higher expectations indirectly contributed to a 0.19 SD increase in marital quality of life via their influence on sexual satisfaction. Likewise, body image exhibited a significant positive indirect effect on marital quality of life through sexual satisfaction (β=0.22, P<0.001), indicating that a better body image indirectly enhanced marital quality of life by 0.22 SDs through the mediating role of sexual satisfaction.

This study examined the interrelationships among marital expectations, body image perception, and marital quality of life in breast cancer patients, while specifically exploring how sexual satisfaction mediates these connections. The initial finding indicated no direct relationship between marital expectations and marital quality of life. This result contrasts with findings reported by Abbaspour et al.²⁷ and Brandão et al.²⁸ While previous studies, using correlation and regression analyses, found a significant direct relationship between marital expectations and marital quality of life, the present study employed path analysis. Although a significant correlation between these variables was also observed here using Pearson’s test, the path model, incorporating a mediating variable, elucidated the influence of marital expectations on marital quality of life through an indirect pathway. Thus, while marital expectations impact marital quality of life in this model, the effect is indirect. One possible explanation is that as individuals become more aware of the responsibilities and skills necessary for successful marital functioning, they may adjust their romanticized and idealistic expectations, such as anticipating constant passion, perfect harmony, or an effortless relationship, focusing instead on fostering a realistic and healthy partnership.²⁸ This shift may subsequently lead to decreased reported marital satisfaction if the adjusted expectations do not align with reality. It can be argued that the degree of marital dissatisfaction couples experience is tied to their marital expectations and beliefs, with those holding more realistic expectations likely facing less conflict and requiring less adaptation to sustain the relationship.²⁷

The results revealed a direct, positive relationship between body image and marital quality of life. This finding aligns with the results reported by previous research.^29,30 This outcome may reflect the significant concerns regarding body image experienced by women with breast cancer. These concerns are influenced by social desirability bias, with some women feeling shame about their altered appearance and struggling to acknowledge these anxieties in the context of a breast cancer diagnosis. Surgical procedures, wounds, and related physical changes contribute to these preoccupations and worries. Such body image concerns can negatively impact spousal relationships and marital quality. These women may perceive a diminished capacity to fulfill their sexual identity and roles within their families and communities due to these bodily changes, potentially leading to feelings of fear, anxiety, and worthlessness. Breast cancer treatments often result in specific physical alterations, including breast deformity, surgical scarring, and skin changes secondary to radiotherapy. Furthermore, adjuvant therapies—additional treatments like chemotherapy or hormone therapy given after primary treatment to lower the risk of cancer recurrence—can frequently lead to weight gain.³⁰ These physical changes are closely associated with body image concerns in women with breast cancer and may contribute to decreased mental well-being, diminished marital quality, and psychological distress stemming from a negative self-perception.

Furthermore, the results indicated a direct, positive relationship between sexual satisfaction and marital quality of life. This finding is consistent with the results found in prior research.^31,32 A satisfying sexual relationship is often predicated on a foundation of intimacy between partners, facilitating open communication about sexual needs and desires.²⁸ Conversely, a lack of sexual intimacy can contribute to tension and dissatisfaction within the marriage. The strength of marital bonds is often linked to satisfying sexual experiences, highlighting the close connection between satisfaction with the marital relationship and satisfaction with the sexual relationship.³² Sexual activity is a crucial aspect of well-being and should be given due consideration in social health, and medical and therapeutic interventions. In women, breast cancer diagnosis can negatively impact sexual satisfaction, which, in turn, will affect marital quality of life. Therefore, neglecting this issue can lead to sexual dissatisfaction and potentially compromise marital relationships.

Additionally, the findings indicate an indirect association between marital expectations and marital quality of life, with sexual satisfaction acting as a mediator. Given the novelty of this specific mediational pathway, there is a paucity of directly comparable studies. The initial analysis revealed no direct link between marital expectations and marital quality of life; however, the indirect effect via sexual satisfaction suggests that marital expectations exert an influence on marital quality of life by modulating sexual satisfaction. This supports the assertion that sexual satisfaction effectively mediates the relationship between marital expectations and marital quality of life. Within the framework of path analysis, the presence of a mediating variable can explain the lack of statistical significance in the direct effect, as the mediator captures the independent variable’s impact on the dependent variable. In this study, although body image did not exhibit a direct association with marital quality of life, its effect was entirely mediated through sexual satisfaction. Broadly, women with breast cancer may develop new expectations concerning emotional, physical, and psychological support from their partners. These expectations can shape their sexual satisfaction, potentially increasing when partners meet these needs. As a vital element of marital life, sexual satisfaction may serve as a mediator, channeling the influence of marital expectations to marital quality of life. Women reporting higher levels of sexual satisfaction are more likely to perceive enhanced marital quality.¹¹ When partners respond adeptly to these expectations—such as by providing greater attention to the woman’s emotional and physical needs following cancer diagnosis—sexual satisfaction can improve, thereby enhancing marital quality of life.

Moreover, the analysis identified an indirect relationship between body image and marital quality of life, with sexual satisfaction serving as a mediator. Although directly comparable research on this specific mediational pathway remains limited, the direct findings demonstrated a significant association between body image and marital quality of life. The indirect effect suggests that body image influences marital quality of life among women with breast cancer by modulating sexual satisfaction. Physical alterations resulting from breast cancer, such as those induced by surgery and associated treatments, can profoundly impact a woman’s body image. Dissatisfaction with physical appearance may erode sexual self-confidence, subsequently reducing satisfaction with sexual activity.¹² Sexual satisfaction acts as a mediating variable, elucidating the intricate relationship between body image and marital quality of life. Women with a positive body image are more likely to report greater satisfaction in their sexual relationships, which contributes to enhanced marital quality. Conversely, a negative body image may diminish libido, directly lowering sexual satisfaction and ultimately adversely affecting marital quality of life.¹⁴ Women who perceive themselves as more attractive due to a positive body image may experience heightened sexual satisfaction, thereby improving their marital quality of life.

This study was conducted on women diagnosed with breast cancer residing in Ahvaz, limiting the generalizability of the findings to women with breast cancer in other regions, particularly those with differing cultural or socio-personal characteristics. Notably, this research did not explicitly examine the influence of cultural factors or religious beliefs on the variables studied, despite their potential to significantly shape perceptions of marital quality of life, marital expectations, body image, and sexual satisfaction. In a context like Ahvaz, where Islamic religious beliefs and cultural expectations may emphasize modesty, familial roles, and resilience, these factors could influence how women perceive their post-diagnosis body image or navigate marital dynamics and sexual intimacy.

To address these gaps, future research could employ longitudinal designs to track how these variables evolve over time—from diagnosis through treatment and recovery—offering deeper insights into their dynamic interplay. Additionally, cross-cultural comparisons, such as between women in Middle Eastern contexts like Ahvaz and those in Western or East Asian settings, could reveal how religious beliefs and cultural norms—such as Islamic values versus secular individualism—differentially impact these psychological and relational outcomes. Specifically, exploring the role of religious coping mechanisms, such as prayer or spiritual support, alongside cultural expectations around gender roles and sexuality, could enhance our understanding and guide the development of culturally and spiritually sensitive interventions.

The findings of this study illuminate the complex interplay of factors influencing marital quality of life among women with breast cancer. The significant direct relationships observed between sexual satisfaction and both marital expectations and body image underscore the importance of addressing these domains in interventions to enhance intimacy and well-being. The direct link between body image and marital quality of life highlights the vulnerability of self-perception post-cancer treatment, impacting relationship dynamics. The mediating role of sexual satisfaction in the relationships between body image, marital expectations, and marital quality of life clarifies these influence pathways. Clinicians can use these insights to design holistic interventions—such as therapy focusing on communication and sexual health, alongside body image support—to improve marital quality of life. The absence of a direct relationship between marital expectations and marital quality of life, with a significant indirect effect via sexual satisfaction, suggests that clinicians should prioritize enhancing sexual intimacy to mitigate unmet expectations, effectively supporting women and their partners.

This study was approved by the Ethics Review Board of the Islamic Azad University Ahvaz Branch (IR.IAU.AHVAZ.REC.1403.177).