Symptom assessment is a fundamental component of quality-oflife

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1 1162 The Memorial Symptom Assessment Scale Short Form (MSAS-SF) Validity and Reliability Victor T. Chang, M.D. 1 Shirley S. Hwang, R.N., A.O.C.N., M.S. 2 Martin Feuerman, M.S. 3 Basil S. Kasimis, M.D., D.Sc. 1 Howard T. Thaler, Ph.D. 4 1 University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Section Hematology/Oncology, VA New Jersey Health Care System at East Orange, East Orange, New Jersey. 2 University of Medicine and Dentistry of New Jersey, Section Hematology/Oncology, Patient Care Services, VA New Jersey Health Care System at East Orange, East Orange, New Jersey. 3 Information Services and Technology, Academic Computing Services, UMDNJ/New Jersey Medical School, Newark, New Jersey. 4 Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York. Presented in part at the Annual Scientific Meeting of the American Society of Clinical Oncology, Denver, Colorado, May 17 20, Chang VT, Hwang SS, Corpion C, Feuerman M. Validation of the Memorial Symptom Assessment Scale Short Form (MSAS-SF) [abstract 16]. Proc Am Soc Clin Oncol 1997;16:47a. Also presented in part at the Third International Conference on Comprehensive Cancer Care, New York, New York, November 12 14, 1999, Chang VT, Hwang SS, Corpion C, Feuerman M. Validation of the Memorial Symptom Assessment Scale Short Form [abstract 71]. J Pain Symptom Manage 1999;18:S20. The authors thank Dr. Russell Portenoy for helpful discussions. Ms Chris Corpion and Ms. Michelle Rindos assisted with interviews. Martin Feuerman s current address: Office of Academic Affairs, Winthrop University Hospital, Mineola, New York. Address for reprints: Victor T. Chang, M.D., UMDNJ New Jersey Medical School, Section Hematology/ Oncology (111), VA New Jersey Health Care System at East Orange, 385 Tremont Avenue, East BACKGROUND. The Memorial Symptom Assessment Scale Short Form (MSAS-SF), an abbreviated version of the Memorial Symptom Assessment Scale, measures each of 32 symptoms with respect to distress or frequency alone. A physical symptom subscale (PHYS), psychologic symptom subscale (PSYCH), and global distress index (GDI) can be derived from the Short Form. We validated the MSAS- SF in a population of cancer patients. METHODS. Two hundred ninety-nine cancer patients examined at the Section of Hematology/Oncology completed the MSAS-SF and the Functional Assessment Cancer Therapy (FACT-G). The Karnofsky performance status (KPS), extent of disease (EOD), and demographic data were assessed. The Cronbach alpha coefficient was used to assess internal reliability. MSAS-SF subscales were assessed against subscales of the FACT-G, the KPS, and EOD to determine criterion validity. Test retest analysis was performed at 1 day and at 1 week. RESULTS. The Cronbach alpha coefficients for the MSAS-SF subscales ranged from 0.76 to The MSAS-SF subscales showed convergent validity with FACT subscales. Correlation coefficients were 0.74 (P 0.001) for the PHYS and FACT-G physical well-being subscales, 0.68 (P 0.001) for the PSYCH and FACT emotional well-being subscales, and 0.70 (P 0.001) for GDI and FACT summary of quality-of-life subscales. The MSAS-SF subscales demonstrated convergent validity with performance status, inpatient status, and extent of disease. The test retest correlation coefficients for the MSAS-SF subscales ranged from 0.86 to 0.94 at 1 day and from 0.40 to 0.84 for the 1 week group. CONCLUSIONS. The MSAS-SF is a valid and easy to use instrument for symptom assessment. Cancer 2000;89: Published 2000 by the American Cancer Society.* KEYWORDS: neoplasm, symptom, Memorial Symptom Assessment Scale, veteran, quality of life. Symptom assessment is a fundamental component of quality-oflife (QOL) assessment in palliative care. Previous approaches to symptom assessments have been based upon one dimensional symptom checklists, 1,2 which often measure symptom severity or symptom distress. The Memorial Symptom Assessment Scale (MSAS) 3 is a validated multidimensional symptom assessment instrument that cap- Orange, NJ 07018;Fax: (973) ; CHANG.VICTOR_T@EAST-ORANGE.VA.GOV The views expressed herein do not necessarily reflect the views of the Department of Veterans Affairs or of the U.S. Government. Received January 10, 2000; revision received May 15, 2000; accepted May 15, *This article is a US Government work, and as such, is in the public domain in the United States of America. Published 2000 by the American Cancer Society*

2 Memorial Symptom Assessment Scale Short Form Validation/Chang et al TABLE 1 Demographics of Study Population Characteristic Overall (n 299) Inpatient (n 149) Outpatient (n 150) Gender (male) Age (yrs) Median (range) 66 (27 89) 64 (27 88) 69 (30 89) Mean SD Tumor type (%) Head and neck 21 (7) 14 (10) 7 (5) Lung 82 (27) 48 (32) 34 (23) GI 55 (19) 21 (14) 34 (23) GU 93 (31) 41 (28) 52 (34) Hematologic 40 (13) 20 (13) 20 (13) Miscellaneous a 8 (3) 5 (3) 3 (2) KPS Median (range) 70 (20 100) 60 (20 100) 80 (20 100) Mean SD SD: standard deviation; GI: gastrointestinal; GU: genitourinary; KPS: Karnofsky performance status. a Miscellaneous inpatients included: sarcoma, 2; melanoma, 1; adenocarcinoma unknown primary, 1; breast, 1. Miscellaneous outpatients: sarcoma, 2; adenocarcinoma unknown primary, 1. tures patient rated severity, frequency, and distress associated with 32 highly prevalent symptoms. Since its introduction, the MSAS has found applications in studies of patients with ovarian carcinoma, 4 breast carcinoma, 5,6 head and neck carcinoma, 7 and cancer pain Comprehensive symptom assessments may be time consuming and difficult for patients to complete, and there is a need for shorter symptom assessment instruments. In a review of QOL tools for patients with cancer, proposed criteria for an ideal instrument included one that would be simple to read and follow, quick and easy to complete and analyze, and based on a categoric or visual analog scale. 11 A shorter version of the MSAS has been developed with one-third the number of questions and has been studied in patients with acquired immune deficiency syndrome. 12 We report the validation of the MSAS Short Form (MSAS-SF) in a population of cancer patients at a Veterans Administration (VA) hospital. MATERIALS AND METHODS Patient Selection and Instruments The Section of Hematology/Oncology of the VA New Jersey Health Care System at East Orange is the referral center in New Jersey for veterans with cancer. Patients who participated in Institutional Review Board approved studies (longitudinal cancer care survey, 13 fatigue survey, 14 development of a cancer pain prognostic scale, 15 and the test retest study) completed the MSAS-SF and Functional Assessment Cancer Therapy (FACT-G) 16 as part of an interview. All patients gave informed consent before participating. Each of these studies enrolled a consecutive group of patients. Patients who enrolled in more than one study were only counted once, and data from other studies were eliminated. Concurrent demographic items, including age, gender, primary cancer diagnosis, extent of disease, and observer rated Karnofsky performance status (KPS) 17 also were gathered. For the test retest study, a convenience group of patients with stable KPS and no acute medical problems was selected. Two convenience groups of rela- TABLE 2 Summary Scores for MSAS-SF and FACT-G Scale All patients (n 299) Inpatient (n 149) Outpatient (n 150) Mean SD Range Mean SD Range Mean SD Range t test a (P value) FACT-G PWB a SFWB NS EWB a FWB a SUMQOL a MSAS-SF GDI a PHYS a PSYCH NS TMSAS a No. of symptoms a MSAS-SF: Memorial Symptom Assessment Scale Short Form; FACT-G: Functional Assessment Cancer Therapy; SD: standard deviation; PWB: physical well-being; SFWB: social/family well-being; NS: not significant; EWB: emotional well-being; FWB: functional well-being; SUMQOL: total FACT-G QOL scores; GDI: global distress index; PHYS: physical symptom distress; PSYCH: psychologic symptom distress; TMSAS: total symptom distress. a Student t test results between inpatients and outpatients, two-tailed P value.

3 1164 CANCER September 1, 2000 / Volume 89 / Number 5 tively stable patients were studied. One group of 23 patients had test retest assessments performed the next day of the MSAS-SF, KPS, and FACT. A second group of 22 patients had test retest assessments performed at a 6 8 day interval. This study was approved by the VA New Jersey Health Care System Institutional Review Board, and patients gave informed consent before participating. The KPS is an 11-point rating scale ranging from 0 to 100 (0, dead; 100, normal function) used to assess patients physical functional level related to cancer and its treatment. The FACT-G (version 3) is a validated 28-item general patient-rated measure of quality of life for cancer patients with any tumor type. Each item is scored from 0 to 4 anchored from not at all to very much. There are 5 subscales: functional well-being (FWB) (7 items), physical well-being (PWB) (7 items), social/family well-being (SFWB) (7 items), relationship with M.D. (RMD) (2 items), and emotional wellbeing (EWB) (5 items) with total QOL score ranging from 0 to 112. The FACT-G has been used widely in clinical trials, is easy to complete, and has demonstrated sensitivity according to performance status and extent of disease. The MSAS-SF is a patient-rated instrument in which patients rate symptom distress associated with 26 physical symptoms and the frequency of 4 psychologic symptoms during the past 7 days. Each symptom is scored from 0 to 4 ranging from no symptom to very much. If the symptom is not present, a value of zero is assigned. Distress is rated on a 5-point (0 4) Likert scale (not at all, 0.8; a little bit, 1.6; somewhat, 2.4; quite a bit, 3.2; very much, 4.0). Frequency of psychologic symptoms is scored as rarely (1), occasionally (2), frequently (3), and almost constantly (4). The sequence of symptoms on the short form differs from that of the standard form. MSAS-SF subscales include: the global distress index (GDI) (4 psychologic symptoms: feeling sad, worrying, feeling irritable, and feeling nervous, and 6 physical symptoms: lack of energy, pain, lack of appetite, feeling drowsy, constipation, dry mouth); the physical symptom distress score (PHYS) comprises 12 prevalent physical symptoms (lack of energy, pain, lack of appetite, feeling drowsy, constipation, dry mouth, nausea, vomiting, change in taste, weight loss, feeling bloated, and dizziness): the psychologic symptom distress score (PSYCH) includes 6 prevalent psychologic symptoms (worrying, feeling sad, feeling nervous, difficulty sleeping, feeling irritable, and difficulty concentrating). The number of symptoms is derived from screening for the presence of 32 symptoms at each interview. TABLE 3A Frequency of Symptoms by MSAS-SF Symptom Frequency (%) Pain 214 (72) Lack of energy 210 (70) Dry mouth 165 (55) Shortness of breath 149 (50) Feeling drowsy 148 (49) Lack of appetite 134 (45) Weight loss 133 (44) Difficulty sleeping 127 (42) Cough 121 (40) Worrying 118 (39) Constipation 115 (38) Numbness and tingling 113 (38) Feeling irritable 106 (35) Feeling sad 104 (35) Food taste 94 (31) Feeling nervous 91 (30) Difficulty concentrating 87 (29) Dizziness 84 (28) Urination 80 (27) Sweats 79 (26) Nausea 75 (25) Feeling bloated 73 (24) Itching 73 (24) Don t look like self 68 (23) Changes in skin 68 (23) Sexual interest 64 (21) Swelling of arms/legs 59 (20) Difficulty swallowing 57 (19) Diarrhea 41 (14) Vomiting 33 (11) Hair loss 28 (9) Mouth sores 26 (9) MSAS-SF: Memorial Symptom Assessment Short Form. Statistical Analysis Cronbach alpha test was performed to assess internal consistency of the MSAS-SF. 18 Pearson pairwise correlation coefficients were calculated between the subscales of the MSAS-SF and of the FACT-G. Correlations between physical well-being subscales of the FACT and the physical symptom distress subscale of the MSAS-SF and between the emotional well-being subscale of the FACT and the psychologic symptom subscale of the MSAS-SF were examined to further assess criterion validity. Spearman correlation coefficients were used to assess the test retest coefficient for the MSAS-SF. Kruskal Wallis analysis of variance was used to compare differences in the MSAS-SF subscales and FACT subscales by KPS. One-way analysis of variance was performed to compare MSAS-SF and FACT scores by extent of disease. Statistical analysis was performed with the STATA program. 19

4 Memorial Symptom Assessment Scale Short Form Validation/Chang et al TABLE 3B Distress for the Most Frequently Reported Symptoms How much did it distress you? Not at all/a little Somewhat Quite a bit/very much Physical symptom N n % n % n % Pain Lack of energy Dry mouth Short of breath Drowsy Lack appetite Weight loss Difficulty sleeping Cough Constipation How frequently did you experience it? Rarely Occasionally/frequently Almost constantly Psychologic symptoms Incidence n % a n % n % Worrying Irritable Sad Nervous a Percentages are of those patients who answered yes to a symptom. TABLE 4 Pearson Correlations between MSAS-SF, FACT-G Subscales, and KPS Scale FACT-G PWB SFWB EWB FWB SUMQOL MSAS-SF PHYS a PSYCH GDI a TMSAS a NS a KPS a P unless specified otherwise. MSAS-SF: Memorial Symptom Assessment Short Form; FACT-G: Functional Assessment Cancer Therapy; PWB: physical well-being; SFWB: social/family well-being; EWB: emotional well-being; FWB: functional well-being; SUMQOL: total FACT-G quality-of-life scores; KPS: Karnofsky performance status; GDI: global distress index; PHYS: physical symptom distress; PSYCH: psychologic symptom distress; TMSAS: total symptom distress; NS: no. of symptoms. a Not significant. RESULTS Patient Characteristics Two hundred ninety-nine patients who met the criteria as specified in the previous section were included for the analysis. These included 41 patients from the KPS longitudinal study at the third visit, 65 patients from the pain study at the first visit, 159 patients from a general survey of inpatients and outpatients, and 34 patients from the test retest study. There were 150 outpatients and 149 inpatients. These studies were a series of studies designed to assess aspects of symptom distress and enrolled consecutive patients. The test retest group was a convenience sample. The median age was 66 years (range, years). Primary cancer sites were head and neck (21%, 7%), lung (82%, 27%), gastrointestinal (55%, 19%), genitourinary (93%, 31%), hematologic (40%, 13%), and other (8%, 3%%). Median KPS was 70% (range, %). Further details are presented in Table 1. There was no evidence of disease (NED) in 19 (6%) patients, localized disease in 7 (2%) patients, regionally advanced disease in 43 (15%) patients, and metastatic disease in 230 (77%) patients. Separate convenience samples of inpatients and outpatients were recruited for test retest reliability analysis. There are 2 groups: 1 day apart and 1 week apart. There were 12 outpatients and 11 inpatients in the 2-day group, and 10 inpatients and 12 outpatients in the 1-week group.

5 1166 CANCER September 1, 2000 / Volume 89 / Number 5 TABLE 5 Variation of MSAS-SF and FACT-G Scores with the Extent of Disease a NED and local (n 26) Regional (n 43) Metastatic (n 230) Scale Mean SD Mean SD Mean SD F P value MSAS-SF PHYS PSYCH GDI TMSAS NS FACT-G PWB SFWB EWB FWB SUMQOL MSAS-SF: Memorial Symptom Assessment Short Form; FACT-G: Functional Assessment Cancer Therapy; NED: no evidence of disease; SD: standard deviation; PHYS: physical symptom subscale; PSYCH: psychologic symptom subscale; GDI: global distress index; TMSAS: total symptom distress; NS: no. of symptoms; PWB: physical well-being; SFWB: social/family well-being; EWB: emotional well-being; FWB: functional well-being; SUMQOL: total FACT-G quality-of-life scores. a Differences between patients with metastatic disease and patients with regional disease/ned were significant but not between the latter two groups. TABLE 6 Variation of MSAS-SF and FACT-G Scores with the KPS a KPS (n 68) KPS (n 78) KPS 80 (n 104) KPS (n 49) Scale Mean SD Mean SD Mean SD Mean SD F P value MSAS-SF PHYS PSYCH GDI TMSAS NS FACT-G PWB SFWB EWB FWB SUMQOL MSAS-SF: Memorial Symptom Assessment Short Form; FACT-G: Functional Assessment Cancer Therapy; KPS: Karnofsky performance status; SD: standard deviation; PHYS: physical symptom subscale; PSYCH: psychologic symptom subscale; GDI: global distress index; TMSAS: total symptom distress; NS: no. of symptoms; PWB: physical well-being; SFWB: social/family well-being; EWB: emotional well-being; FWB: functional well-being; SUMQOL: total FACT-G quality-of-life scores. a Comparisons were made with Kruskal Wallis test, two-tailed P value. Summary Scores for MSAS-SF and FACT-G The summary scores for the MSAS-SF and FACT-G subscales are listed in Table 2. The mean number of symptoms was 10.5 (range, 0 26) for the entire study population, 11.1 for inpatients and 9.8 for outpatients. Comparisons of scores between inpatient and outpatient groups are listed in Table 2. The inpatients had significantly higher symptom distress scores in the PHYS subscale (P 0.02), GDI (P 0.03), total symptom distress (TMSAS) (P 0.02), and number of symptoms (P 0.046) of the MSAS-SF. Inpatients had significantly lower FACT scores in the domains of PWB (P 0.002), EWB (P 0.03), FWB (P 0.03), and total FACT-G QOL (SUMQOL) scores (P 0.04). Symptom Prevalence by MSAS-SF The most frequently reported physical symptoms included pain (72%), lack of energy (70%), dry mouth (55%), shortness of breath (50%), feeling drowsy (49%), lack of appetite (45%), weight loss

6 Memorial Symptom Assessment Scale Short Form Validation/Chang et al TABLE 7 Test Retest Results a Scale 1 day (n 23) 1 week (n 22) r P value r P value number of symptoms is closely correlated with the SUMQOL score on the FACT instrument. Criterion validity was further established by demonstrating appropriate and significant correlations between the MSAS-SF parameters and the KPS. FACT-G PWB SFWB NS EWB FWB SUMQOL MSAS-SF PHYS PSYCH TMSAS GDI No. of symptoms KPS FACT-G: Functional Assessment Cancer Therapy; SFWB: social/family well-being; EWB: emotional well-being; FWB: functional well-being; SUMQOL: total FACT-G quality-of-life scores; MSAS-SF: Memorial Symptom Assessment Scale Short Form; PHYS: physical symptom subscale; PSYCH: psychological symptom subscale; TMSAS: total symptom distress; GDI: global distress index; KPS: Karnofsky performance status. a Spearman correlation coefficients and associated probabilities are reported. (44%), difficulty sleeping (42%), cough (40%), and constipation (38%). Among these symptoms, except for cough, greater than 50% of patients reported that the distress caused by each symptom was at least somewhat. However, greater than 50% of the patients with pain or lack of energy reported quite a bit or very much symptom distress. The most frequent psychologic symptoms included worrying (39%), feeling irritable (35%), and feeling sad (35%). The majority of patients experienced psychologic symptoms occasionally. Complete data are listed in Tables 3A and 3B. MSAS-SF Reliability All the MSAS subscales were reliable in the MSAS-SF. The Cronbach alpha coefficient was 0.80 for the GDI, 0.82 for the physical symptom distress (PHYS), 0.76 for the psychologic symptom distress (PSYCH), and 0.87 for the TMSAS. Criterion Validity The MSAS-SF subscale scores were assessed against subscales of the FACT-G with pairwise Pearson correlation coefficients (Table 4). Correlation coefficients were 0.74 (P 0.001) for the PHYS and FACT-G PWB, 0.68 (P 0.001) for the PSYCH and FACT-G EWB, and 0.70 (P 0.001) for GDI and FACT-G SUMQOL score. Of the MSAS-SF subscales, only PSYCH correlated significantly with FACT SFWB. The Convergent Validity Based on the KPS, Extent of Disease, and Inpatient Status Further analysis was performed to assess the sensitivity of MSAS-SF subscales to the KPS and extent of disease. The results are listed on Tables 5 and 6. In summary, MSAS-SF subscale scores showed a sharp boundary between patients with and without metastatic disease. Patients with metastatic disease (n 230) exhibited significantly higher number of symptoms, physical and psychologic distress subscales, global distress subscale, and total MSAS scores compared with patients with NED/local (n 26) and regional disease (n 43) groups. Similar observations also were recorded for the FACT subscales and SUMQOL scores measured by FACT-G. One-way analysis of variance analysis was performed to compare the means in MSAS-SF and FACT-G parameters among 4 different KPS categories (KPS 20 50%, n 68; KPS 60 70%, n 78; KPS 80%, n 104; and KPS %, n 49) as convenience groups. The results, shown in Table 6, indicate that all the MSAS-SF subscales scores differed significantly between different KPS categories. Analyses by KPS quartiles yielded similar results. FACT- G subscale scores also exhibited significant sensitivity to KPS. MSAS-SF and FACT subscales differed significantly for inpatients and outpatients except for the FACT SFWB and for the MSAS psychologic subscale. Test Retest Reliability The test retest study was performed to assess the coefficient of stability. Spearman pairwise correlation coefficients are listed on Table 7. Statistically significant correlations were observed for the two test retest groups; however, the magnitude was different. For the 1-day test retest group, the coefficients were strongly significant ranging from 0.70 to 0.90 for FACT-G subscales, 0.95 for KPS, and ranging from 0.86 to 0.94 for MSAS-SF scores. However, for the 1-week test retest group, the coefficients were for FACT-G subscales, 0.94 for KPS, and ranged from 0.40 to 0.84 for MSAS-SF scores. For both FACT-G and MSAS-SF, significant correlations are present at 2 days and 1 week, and correlations are much higher at 1 day than at 1 week.

7 1168 CANCER September 1, 2000 / Volume 89 / Number 5 FIGURE 1. Facsimile of the revised Memorial Symptom Assessment Scale Short Form is shown.

8 Memorial Symptom Assessment Scale Short Form Validation/Chang et al FIGURE 1. (continued) Comparison of Results with Previous Studies Values of the MSAS-SF subscales and their correlation with FACT subscales were compared with a previous study of 240 VA patients in which the MSAS and the FACT were used. Although the two populations studied are somewhat different, correlation coefficients between subscales of the FACT-G and MSAS and FACT-G and MSAS-SF were nearly identical, except for SFWB, in which coefficients were weaker or insignificant between the MSAS-SF and FACT-G. DISCUSSION Because patients with cancer have multiple physical and psychologic symptoms, comprehensive symptom assessment is a requisite toward good symptom control and an important component of QOL assessment. This need has led to the development of scales that elicit patient rated symptom reports, including the Edmonton Symptom Assessment Scale, 20,2122 the Lung Cancer Symptom Scale, 23 and the Rotterdam Symptom Checklist. 24 These instruments have measured one dimension, typically severity or distress, for multiple symptoms selected by consensus panels or expert opinion. Previous studies have shown that different dimensions of symptoms may be important in symptom assessment. 25 This led to development of the Memorial Symptom Assessment Scale, which showed that summary scores from multidimensional measurements of physical and psychologic symptom can be used to fashion scales that are highly correlated with quality of life. 26 Analysis of the MSAS suggested that physical symptom distress and frequency of psychologic symptom frequency most closely correlated with QOL measures. The MSAS-SF selects these specific dimensions for symptom assessment. The development of the MSAS-SF suggests how a QOL analysis may guide the development of shorter instruments to assess the impact of symptoms on QOL. Such instruments may be more useful in a clinical setting; the full MSAS is still recommended for research purposes. Further work is in progress. 27 In this study, we found that responses to the MSAS-SF showed internal reliability by Cronbach alpha coefficients. We also found that criterion validity was present. The summary parameters for physical and psychologic symptom distress of the short form correlated well with corresponding parameters in the FACT-G instrument, with inpatient/outpatient status, and with the KSP. The close correlation of the number of symptoms with the FACT SUMQOL score that has been noted in previous work is confirmed in this study. The test retest results show a high correlation coefficient for reassessments the day after and a lower but still significant correlation coefficient at 1 week. The optimal interval for test retest evaluation is not yet known. Intervals have included 4 days for the FACT and the European Organization for Research Treatment of Cancer QLQ-C30, 28 and 1 week for the FACT brain subscale. 29 Test retest data have not been reported yet for the MSAS-SF. We anticipated seeing more variation at 1 week retest than 1 day retest because patients may change clinically over time. These values suggest that the MSAS-SF is a sensitive instrument and that the scale should be reset for a time interval of 2 days instead of 1 week. There are many possible reasons for the decreased correlation at 1 week. One reason may be that patients with advanced disease may be more unstable, and that these changes are captured by the MSAS-SF. However, other factors, such as changes in the patient s perceptions of symptoms, are also possible. This was a small sample size, and further work is needed. The population that completed this study differed from the population we last reported 30 in that patients had a lower KPS, a larger percentage of patients had metastatic disease, and a slightly different profile of

9 1170 CANCER September 1, 2000 / Volume 89 / Number 5 primary disease sites was observed. The FACT-G subscale scores were lower. Higher MSAS symptom prevalence and higher symptom distress scores also were observed in the overall population in comparison with our previous survey. 7 When correlations of the MSAS- SF subscales are compared with correlations of the full MSAS instrument with the FACT, correlation coefficients between the MSAS-SF subscales and FACT subscales were nearly identical to those of the MSAS for PWB, EWB, and FWB domains. They decreased significantly for SFWB, with only the correlation coefficient between MSAS PSYCH and SFWB retaining statistical significance. This suggests that for most dimensions of quality of life, findings on the MSAS-SF are similar to those for the parent MSAS instrument. Further study is needed to confirm and explore the reasons for a decreased correlation between MSAS-SF subscale scores and the FACT SFWB subscale. MSAS-SF subscale scores varied significantly and appropriately with KPS and extent of disease. Scores greater than 1.0 for any of the MSAS-SF subscales should suggest the presence of significant symptom distress. Interpretation of these scores, including the clinical meaning of magnitude of differences in MSAS scores, will be clarified further as more populations are studied. The KPS, FACT, and MSAS-SF measure different aspects of QOL. The KPS emphasizes performance and function, the FACT provides information on the dimensions relevant to quality of life, and the MSAS-SF provides a detailed symptom assessment. The KPS is valuable for prognosis but does not indicate what steps the practitioner can take to help patients with poor performance status. The information from QOL instruments and from symptom instruments complements that from the KSP. 31 In a pilot study of QOL instruments in an office setting, both patients and physicians found discussions of QOL to be helpful. 32 Similarly, the use of symptom assessment instruments may help guide health professionals in directing palliative care efforts for patients with poor performance status. The MSAS-SF was easy to administer and took less than 5 minutes to complete. These findings suggest that patients can be rapidly and comprehensively assessed for symptoms with instruments such as the MSAS-SF. For patients with limited stamina, the short form may be an effective instrument. For a more complete assessment of symptoms, however, the full MSAS may be more informative. An occasional problem with the MSAS-SF was that some patients equated the box for not having a symptom with the adjacent box for not being bothered by the symptom. To correct this problem, the form has been revised so that the first box is checked if the patient has the symptom (Fig, 1). The population studied was primarily elderly male patients with advanced disease and heterogeneous diagnoses. As such, it differs from the initial population of patients with carcinoma of the breast, ovary, prostate, or colon. The findings of good correlations between the MSAS-SF and FACT-G in a different population suggests that the MSAS-SF may be a robust instrument across different populations. A small fraction of patients were in complete remission. Data from these patients were included in the analyses because oncologists do see patients in complete remission. This mean values for this group did not differ to much from those with local disease. Other populations, such as patients with early disease and women, should be studied with this instrument. As data from different patient groups are collected and compared, the interpretation of scores can be determined more precisely. Another possible limitation may be that scoring the form may be tedious. This can be resolved with an automated data entry program. We conclude that the MSAS-SF is a valid instrument for symptom assessment in the VA population. REFERENCES 1. Brodman K, Erdmann AJ, Lorge I, Woff HG. The Cornell Medical Index, an adjunct to the medical interview. JAMA 1949;140: Osoba D. Self-rating symptom checklists: a simple method for recording and evaluating symptom control in oncology. Cancer Treat Rev 1993;19(Suppl A): Portenoy RK, Thaler HT, Kornblith AB, Lepore J, Friedlander-Klar H, Kiyasu E, et al. The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics, and distress. Eur J Cancer 1994; 30A: Kornblith AB, Thaler HT, Wong G, Vlamis V, Lepore JM, Loseth DB, et al. Quality of life of women with ovarian cancer. Gynecol Oncol 1995;59: Seidman AD, Portenoy RK, Yao TJ, Lepore J, Mont EK, Kormansky J, et al. Quality of life in phase II trials: a study of methodology and predictive value in patients with advanced breast cancer treated with paclitaxel plus granulocyte colony-stimulating factor. J Natl Cancer Inst 1995;87: Hann DM, Jacobsen PB, Martin SC, Kronish LE, Azzarello LM, Fields KK. Quality of life following bone marrow transplantation for breast cancer: a comparative study. Bone Marrow Transplant 1997;19: Harrison LV, Zelefsky MJ, Pfister DG, Carper E, Raben A, Kraus DH, et al. Detailed quality of life assessment in patients treated with primary radiotherapy for squamous cell cancer of the base of the tongue. Head Neck 1997;19: Du Pen S, Du Pen AR, Hansberry J, Kraybill BM, Stillman M, Panke J, et al. Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. J Clin Oncol 1999;17: Ingham J, Seidman A, Yao TJ, Lepore J, Portenoy R. An exploratory study of frequent pain measurement in a cancer clinical trial. Qual Life Res 1996;5:503 7.

10 Memorial Symptom Assessment Scale Short Form Validation/Chang et al Payne R, Mathias SD, Pasta DJ, Wanke LA, Williams R, Mahmoud R. Quality of life and cancer pain: satisfaction and side effects with transdermal fentanyl versus oral morphine. J Clin Oncol 1998;16: Donnelly S, Walsh TD. Quality of life assessment in advanced cancer. Palliat Med 1996;10: Vogl D, Rosenfeld B, Breitbart W, Thaler H, Passik S, McDonald M, et al. Symptom prevalence, characteristics, and distress in AIDS outpatients. J Pain Symptom Manage 1999;18: Hwang SS, Chang VT, Fairclough DL. Longitudinal measurements for quality of life and symptoms in terminal cancer patients [abstract]. Proc ASCO 1996;15: Hwang SS, Chang VT, Cogswell J, Ohanian M, Kasimis B. Fatigue (F), depression, symptom distress (SD), quality of life (QOL) and survival (S) in male cancer patients (pts) at a VA Medical Center [abstract]. Proc Am Soc Clin Oncol 1999; 18:594a. 15. Hwang SS, Chang VT, Corpion C, Kasimis B. Outcomes of cancer pain management based upon AHCPR guidelines: pain relief and quality of life (QOL) [abstract]. Proc Am Soc Clin Oncol 1998;17:61a. 16. Cella DF, Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A, et al. The Functional Assessment of Cancer Therapy Scale: development and validation of the general measure. J Clin Oncol 1993;11: Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, editor. Evaluation of chemotherapeutic agents. New York: Columbia University Press, 1949: Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrica 1951;16: StatCorp. Stata Statistical Software: Release 5.0. College Station, TX: Stata Corporation, Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991;7: Chang VT, Hwang SS, Feuerman M. Validation of the Edmonton Symptom Assessment Scale. Cancer 2000;88: McCorkle R, Young K. Development of a symptom distress scale. Cancer Nurs 1978;1: Hollen PJ, Gralla RJ, Kris MG, Cox C, Belani CP, Grunberg SM, et al Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. Cancer 1994; 73: De Haes JCJM, van Knippenberg FCE, Nejit JP. Measuring psychological and physical distress in cancer patients: structure and application of the Rotterdam Symptom Checklist. Br J Cancer 1990;62: Portenoy RK, Miransky J, Thaler HT, Hornung J, Bianchi C, Cibas-Kong I, et al. Pain in ambulatory patients with lung or colon cancer. Prevalence, characteristics and effect. Cancer 1992;70: Portenoy RK, Thaler HT, Kornblith AB, Lepore J, Friedlander-Klar H, Coyle N, et al. Symptom prevalence, characteristics, and distress in a cancer population. Qual Life Res 1994; 3: Chang VT, Hwang SS, Kasimis B, Thaler HT. Shorter symptom assessment instruments [abstract]. Proc Am Soc Clin Oncol 1999;18:583a. 28. Hjermstad MJ, Fossa SD, Bjordal K, Kaasa S. Test/retest study of the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire. J Clin Oncol 1995;13: Weitzner MA, Meyers CA, Gelke CK, Byrne KS, Cella DF, Levin VA. The Functional Assessment of Cancer Therapy (FACT) Scale. Development of a brain subscale and revalidation of the general version (FACT-G) in patients with primary brain tumors. Cancer 1995;75: Chang VT, Hwang SS, Kasimis BS. Symptom and quality of life survey of oncology patients at a VA Medical Center. Cancer 2000;88: Schaafsma J, Osoba D. The Karnofsky performance status scale re-examined: a cross-validation with the EORTC C30. Qual Life Res 1994;3: Detmar SB, Aaronson NK. Quality of life assessment in daily oncology practice: a feasibility study. Eur J Cancer 1998;34: